MEDICARE: VAN EDEN CAVE MC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	LPC-2363	AZ

General Provider Information

NPI Number	:	1063585446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VAN EDEN CAVE MC, LPC

Provider Business Mailing Address
First Line	:	20165 N 67TH AVE
Second Line	:	SUITE 122A PMB 144
City	:	GLENDALE
State	:	AZ
Zip	:	85308-7002
Country	:	US
Telephone Number	:	602-485-1245
Fax Number	:	623-878-0233

Provider Business Practice Location Address
First Line	:	7075 W BELL RD
Second Line	:	SUITE 3
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8546
Country	:	US
Telephone Number	:	602-485-1245
Fax Number	:	623-878-0233

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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