Provider Demographics
NPI:1093968703
Name:VAN SLYKE, MARJORIE ANN (PSYD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ANN
Last Name:VAN SLYKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 VERNON AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2801
Mailing Address - Country:US
Mailing Address - Phone:952-927-4609
Mailing Address - Fax:
Practice Address - Street 1:4021 VERNON AVE S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2801
Practice Address - Country:US
Practice Address - Phone:952-927-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional