Healthcare Provider Details

I. General information

NPI: 1295761070
Provider Name (Legal Business Name): MRS. BETH A. VANDENBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 PLEASANT VIEW DR
LANCASTER NY
14086-1404
US

IV. Provider business mailing address

580 PLEASANT VIEW DR
LANCASTER NY
14086-1404
US

V. Phone/Fax

Practice location:
  • Phone: 716-685-6730
  • Fax: 716-407-0570
Mailing address:
  • Phone: 716-685-6730
  • Fax: 716-407-0570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number279388-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: