MEDICARE: KEVIN VAN MIDDELBURG ACMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor
2	221700000X	Art Therapist

General Provider Information

NPI Number	:	1912741083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN VAN MIDDELBURG ACMHC

Provider Business Mailing Address
First Line	:	PO BOX 271102
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-1102
Country	:	US
Telephone Number	:	385-548-1925
Fax Number	:

Provider Business Practice Location Address
First Line	:	7025 S PARK CENTRE DR
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-6619
Country	:	US
Telephone Number	:	385-548-1925
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2024
Last Update Date	:	02/02/2026

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