Provider Demographics
NPI:1871847780
Name:VANGORDER, MICHAEL GREG (LMSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GREG
Last Name:VANGORDER
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:MR
Other - First Name:MIKE
Other - Middle Name:GREG
Other - Last Name:VAN GORDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:216 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARLES CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50616-2017
Mailing Address - Country:US
Mailing Address - Phone:641-228-2050
Mailing Address - Fax:
Practice Address - Street 1:216 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-2017
Practice Address - Country:US
Practice Address - Phone:641-228-2050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA065881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical