Provider Demographics
NPI:1265522213
Name:VANDERGON, CONSTANCE JO (MS, LP)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:JO
Last Name:VANDERGON
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6867 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2483
Mailing Address - Country:US
Mailing Address - Phone:651-340-5189
Mailing Address - Fax:
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2496103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling