=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376634519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GARY VANN PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 11/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13561 SOUTH WEST BAYSHORE DR. STE. 317
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-947-2990
-----------------------------------------------------
Fax | 231-947-5862
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13561 SOUTH WEST BAYSHORE DRIVE STE 317
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-947-2990
-----------------------------------------------------
Fax | 231-947-5862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 008156
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------