Provider Demographics
NPI:1215036934
Name:VAN SLYKE, SARA (LISW-S)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:VAN SLYKE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:LUIDENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LISW
Mailing Address - Street 1:16920 SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9616
Mailing Address - Country:US
Mailing Address - Phone:937-642-0048
Mailing Address - Fax:937-642-1316
Practice Address - Street 1:16920 SQUARE DRIVE
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-642-0048
Practice Address - Fax:937-642-1316
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0030887104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker