MEDICARE: JONATHAN ROYCE VANDERVLUGT LMHCA

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	103TC1900X	Counseling Psychologist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1215534037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN ROYCE VANDERVLUGT LMHCA

Provider Business Mailing Address
First Line	:	9614 GRANADA CT APT 111
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-2161
Country	:	US
Telephone Number	:	773-732-1155
Fax Number	:

Provider Business Practice Location Address
First Line	:	9614 GRANADA CT APT 111
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-2161
Country	:	US
Telephone Number	:	773-732-1155
Fax Number	:

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

Provider Enumeration Date	:	10/05/2020
Last Update Date	:	10/12/2020

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