Provider Demographics
NPI:1023410107
Name:VANDENBERG, ALICIA ANN (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:ANN
Last Name:VANDENBERG
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 ARIEL ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-2248
Mailing Address - Country:US
Mailing Address - Phone:651-254-4793
Mailing Address - Fax:651-254-0877
Practice Address - Street 1:2345 ARIEL ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-2248
Practice Address - Country:US
Practice Address - Phone:651-254-4793
Practice Address - Fax:651-254-0877
Is Sole Proprietor?:No
Enumeration Date:2014-09-21
Last Update Date:2014-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN159241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical