Provider Demographics
NPI:1184805988
Name:VANDERMOSS, CONSTANCE MARY (BS, MS)
Entity type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:MARY
Last Name:VANDERMOSS
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6055 GOLDEN CT
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-7464
Mailing Address - Country:US
Mailing Address - Phone:920-739-6273
Mailing Address - Fax:
Practice Address - Street 1:3375 W BREWSTER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-1602
Practice Address - Country:US
Practice Address - Phone:920-749-5870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI342-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42770700Medicaid