Healthcare Provider Details

I. General information

NPI: 1639967227
Provider Name (Legal Business Name): DESIREE M VANDERLICK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E BROAD ST STE 5
HAZLETON PA
18201-5657
US

IV. Provider business mailing address

1730 E BROAD ST STE 5
HAZLETON PA
18201-5657
US

V. Phone/Fax

Practice location:
  • Phone: 570-266-2155
  • Fax:
Mailing address:
  • Phone: 570-266-2155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC019861
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: