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General NPI Number Information
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NPI Number | 1265522213
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Entity Type | Individual
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Provider Name | CONSTANCE JO VANDERGON M.S., L.P.
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Gender | Female
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Dates
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Enumeration Date | 10/13/2006
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Last Update Date | 10/24/2018
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Provider Practice Location Address
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Address Line | 1930 COON RAPIDS BLVD NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-4708
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Country | US
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Telephone | 763-427-7964
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Fax | 763-427-7976
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Provider Business Mailing Address
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Address Line | 6867 SHERWOOD RD
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City | WOODBURY
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State | MN
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Zip | 55125-2483
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Country | US
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Telephone | 651-340-5189
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number | LP2496
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License Number State | MN
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