Provider Demographics
NPI:1639669443
Name:VANDENENG, MEGAN MARIE
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIE
Last Name:VANDENENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1156 MINNEHAHA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1402
Mailing Address - Country:US
Mailing Address - Phone:920-419-1891
Mailing Address - Fax:
Practice Address - Street 1:3395 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3765
Practice Address - Country:US
Practice Address - Phone:952-939-0396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst