=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144006768
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA VANDAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2023
-----------------------------------------------------
Last Update Date | 09/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1425 W ELLIOT RD
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85233-5129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-223-0223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21333 N KARSTEN DR
-----------------------------------------------------
City | MARICOPA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85138-1553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-450-0741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LPC-22477
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------