Provider Demographics
NPI:1356101513
Name:VANGELDER, MIKENNA JUNE (CBT)
Entity type:Individual
Prefix:
First Name:MIKENNA
Middle Name:JUNE
Last Name:VANGELDER
Suffix:
Gender:F
Credentials:CBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 N HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-2474
Mailing Address - Country:US
Mailing Address - Phone:866-240-0808
Mailing Address - Fax:
Practice Address - Street 1:1720 N HAMILTON ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-2474
Practice Address - Country:US
Practice Address - Phone:866-240-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-22
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61495799106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician