Healthcare Provider Details

I. General information

NPI: 1780657106
Provider Name (Legal Business Name): MICHAEL VANCLEVE MA LP LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W SUITE 435S
SAINT PAUL MN
55114-1052
US

IV. Provider business mailing address

1374 SHELDON ST
SAINT PAUL MN
55108-2411
US

V. Phone/Fax

Practice location:
  • Phone: 651-647-1900
  • Fax: 651-647-1861
Mailing address:
  • Phone: 651-647-5602
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberLP3135
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: