Provider Demographics
NPI:1841969151
Name:VANDENBOOM, MICAELLA MARIA (LPC)
Entity type:Individual
Prefix:
First Name:MICAELLA
Middle Name:MARIA
Last Name:VANDENBOOM
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MICAELLA
Other - Middle Name:M
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:1325 ANGELS PATH
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-4050
Practice Address - Country:US
Practice Address - Phone:920-338-2855
Practice Address - Fax:920-338-9270
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7857-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional