Provider Demographics
NPI:1730472853
Name:VREDEVOOGD, HEATHER JEAN
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:JEAN
Last Name:VREDEVOOGD
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 1:1616 CORNWALL AVE
Mailing Address - Street 2:STE 205
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4648
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:
Practice Address - Street 1:1616 CORNWALL AVE
Practice Address - Street 2:STE 205
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4648
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60210760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health