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General NPI Number Information
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NPI Number | 1063585446
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Entity Type | Individual
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Provider Name | VAN EDEN CAVE MC, LPC
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Gender | Male
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Dates
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Enumeration Date | 11/15/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 7075 W BELL RD SUITE 3
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City | GLENDALE
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State | AZ
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Zip | 85308-8546
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Country | US
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Telephone | 602-485-1245
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Fax | 623-878-0233
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Provider Business Mailing Address
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Address Line | 20165 N 67TH AVE SUITE 122A PMB 144
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City | GLENDALE
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State | AZ
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Zip | 85308-7002
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Country | US
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Telephone | 602-485-1245
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Fax | 623-878-0233
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPC-2363
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License Number State | AZ
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