Healthcare Provider Details

I. General information

NPI: 1457672164
Provider Name (Legal Business Name): MICHAEL DEAN VANSICE MSW, LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 RODEO PARK DR W
SANTA FE NM
87505-6351
US

IV. Provider business mailing address

991 SIRINGO RONDO E
SANTA FE NM
87507-5017
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-9633
  • Fax:
Mailing address:
  • Phone: 505-603-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberX-07013
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: