Healthcare Provider Details

I. General information

NPI: 1568858470
Provider Name (Legal Business Name): AMY VREDENBURGH M.A., L.M.F.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 STANLEY AVE
CLOQUET MN
55720-3186
US

IV. Provider business mailing address

9450 SW GEMINI DR PMB 14034
BEAVERTON OR
97008
US

V. Phone/Fax

Practice location:
  • Phone: 612-876-6586
  • Fax: 218-585-1586
Mailing address:
  • Phone: 612-876-6586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2962
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2962
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: