Provider Demographics
NPI:1043293855
Name:VAN DER SLUIS, LANE (PSY D)
Entity Type:Individual
Prefix:DR
First Name:LANE
Middle Name:
Last Name:VAN DER SLUIS
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:LA CENTER
Mailing Address - State:WA
Mailing Address - Zip Code:98629-0213
Mailing Address - Country:US
Mailing Address - Phone:360-695-8332
Mailing Address - Fax:360-263-5911
Practice Address - Street 1:2904 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2722
Practice Address - Country:US
Practice Address - Phone:360-695-8332
Practice Address - Fax:360-263-5911
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00001784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical