Provider Demographics
NPI:1760627657
Name:VANDERGIESSEN, DANA L (LCPC)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:L
Last Name:VANDERGIESSEN
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 STAGECOACH WAY
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2341
Mailing Address - Country:US
Mailing Address - Phone:208-420-3199
Mailing Address - Fax:
Practice Address - Street 1:2770 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5953
Practice Address - Country:US
Practice Address - Phone:208-855-0660
Practice Address - Fax:208-898-9433
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC4166101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor