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General NPI Number Information
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NPI Number | 1881409266
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Entity Type | Individual
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Provider Name | SO-YOUNG VANDERGAST
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Gender | Female
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Dates
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Enumeration Date | 02/11/2025
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Last Update Date | 02/11/2025
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Provider Practice Location Address
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Address Line | 161 EAGLE ROCK AVE STE 2
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City | ROSELAND
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State | NJ
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Zip | 07068-1354
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Country | US
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Telephone | 973-932-4195
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Fax |
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Provider Business Mailing Address
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Address Line | 3100 RACHEL TER APT 15
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City | PINE BROOK
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State | NJ
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Zip | 07058-9347
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Country | US
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Telephone | 973-932-4195
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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 | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 25MZ00175200
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License Number State | NJ
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