MEDICARE: GREGORY VAN DAM, PSY.D. LLC

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	103TC0700X	Clinical Psychologist	PY 8572	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689922528
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY VAN DAM, PSY.D. LLC

Provider Business Mailing Address
First Line	:	1936 LEE RD
Second Line	:	SUITE 290
City	:	WINTER PARK
State	:	FL
Zip	:	32789-7229
Country	:	US
Telephone Number	:	407-233-1864
Fax Number	:	407-563-3264

Provider Business Practice Location Address
First Line	:	1936 LEE RD
Second Line	:	SUITE 290
City	:	WINTER PARK
State	:	FL
Zip	:	32789-7229
Country	:	US
Telephone Number	:	407-233-1864
Fax Number	:	407-563-3264

Authorized Official
Title or Position	:	OWNER
Name	:	DR. GREGORY VAN DAM
Credential	:	PSY.D.
Telephone Number	:	561-252-7336

Provider Enumeration Date	:	08/27/2012
Last Update Date	:	04/12/2017

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