Provider Demographics
NPI:1548988173
Name:VANGILDER, SANDRA ELLEN
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:ELLEN
Last Name:VANGILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4555 N RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-8924
Mailing Address - Country:US
Mailing Address - Phone:815-219-2260
Mailing Address - Fax:
Practice Address - Street 1:4555 N RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-8924
Practice Address - Country:US
Practice Address - Phone:815-219-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33009441A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)