Provider Demographics
NPI:1679839765
Name:VANGILDER, ILENE J
Entity Type:Individual
Prefix:
First Name:ILENE
Middle Name:J
Last Name:VANGILDER
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:BEAVER SPRINGS
Mailing Address - State:PA
Mailing Address - Zip Code:17812
Mailing Address - Country:US
Mailing Address - Phone:570-658-7710
Mailing Address - Fax:
Practice Address - Street 1:730 SNYDER AVENUE
Practice Address - Street 2:
Practice Address - City:BEAVER SPRINGS
Practice Address - State:PA
Practice Address - Zip Code:17812
Practice Address - Country:US
Practice Address - Phone:570-658-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA126252104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker