Provider Demographics
NPI:1285457333
Name:BULLINGER, VANESSA (LADC)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:BULLINGER
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:BURGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LADC
Mailing Address - Street 1:13100 WAYZATA BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1810
Mailing Address - Country:US
Mailing Address - Phone:218-331-4866
Mailing Address - Fax:
Practice Address - Street 1:13100 WAYZATA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1810
Practice Address - Country:US
Practice Address - Phone:218-331-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306456101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)