Healthcare Provider Details

I. General information

NPI: 1598086076
Provider Name (Legal Business Name): MICHAEL ALLEN VANSLYKE BA, LISAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 06/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 N CHOLLA LN
CASA GRANDE AZ
85194-6896
US

IV. Provider business mailing address

6540 N CHOLLA LN
CASA GRANDE AZ
85194-6896
US

V. Phone/Fax

Practice location:
  • Phone: 520-836-1675
  • Fax:
Mailing address:
  • Phone: 520-836-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLISAC-10197
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: