Provider Demographics
NPI:1295131779
Name:VANDA COUNSELING AND PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:VANDA COUNSELING AND PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANSTELTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:763-370-2031
Mailing Address - Street 1:14115 JAMES RD STE 305
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9417
Mailing Address - Country:US
Mailing Address - Phone:763-575-8086
Mailing Address - Fax:
Practice Address - Street 1:14115 JAMES RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9468
Practice Address - Country:US
Practice Address - Phone:763-575-8086
Practice Address - Fax:320-774-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-11
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4781251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN817465000Medicaid