Healthcare Provider Details

I. General information

NPI: 1134195431
Provider Name (Legal Business Name): AUGUST VANDERBEEK PSY D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SOUTH PAGOSA BLVD
PAGOSA SPRINGS CO
81147
US

IV. Provider business mailing address

581 RAINBOW DR
PAGOSA SPRINGS CO
81147
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-3969
  • Fax:
Mailing address:
  • Phone: 970-264-6216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2354
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5010
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: