Provider Demographics
NPI:1548326861
Name:VANG, PA DER (LICSW)
Entity type:Individual
Prefix:DR
First Name:PA
Middle Name:DER
Last Name:VANG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7421 CHESHAM LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2726
Mailing Address - Country:US
Mailing Address - Phone:651-210-9534
Mailing Address - Fax:
Practice Address - Street 1:916 RICE ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55117-5425
Practice Address - Country:US
Practice Address - Phone:651-290-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN165111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN221657400OtherMN HEALTHCARE PROVIDER #