Provider Demographics
NPI:1700087756
Name:VANDERGAST, TIM S (MA, NCC)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:S
Last Name:VANDERGAST
Suffix:
Gender:M
Credentials:MA, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3967 TENNEYSON CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-8119
Mailing Address - Country:US
Mailing Address - Phone:704-210-8450
Mailing Address - Fax:
Practice Address - Street 1:952 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2433
Practice Address - Country:US
Practice Address - Phone:704-786-7709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45941101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor