Basic Information
| Provider Information | |||||||||
| NPI: | 1295131779 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANDA COUNSELING AND PSYCHOLOGICAL SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14115 JAMES RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553749417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635758086 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14115 JAMES RD | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553749468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635758086 | ||||||||
| FaxNumber: | 3207740415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2014 | ||||||||
| LastUpdateDate: | 04/18/2018 | ||||||||
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| AuthorizedOfficialLastName: | VANSTELTEN | ||||||||
| AuthorizedOfficialFirstName: | ANTOINETTE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CO-OWNER/PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 7633702031 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PSYD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4781 | MN | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 817465000 | 05 | MN | MEDICAID |