Provider Demographics
NPI:1912168832
Name:VANDER SANDE, PAUL EDWIN (L C P C)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:EDWIN
Last Name:VANDER SANDE
Suffix:
Gender:M
Credentials:L C P C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 DEAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-1068
Mailing Address - Country:US
Mailing Address - Phone:630-443-7754
Mailing Address - Fax:
Practice Address - Street 1:2320 DEAN ST STE 101
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60175-1068
Practice Address - Country:US
Practice Address - Phone:630-443-7754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-002779101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional