Provider Demographics
NPI:1265862452
Name:VAN VOLKINBURGH, KERRY (MA,LPC)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:VAN VOLKINBURGH
Suffix:
Gender:M
Credentials:MA,LPC
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 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:291 W. CASA BLANCA RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-0001
Practice Address - Country:US
Practice Address - Phone:520-562-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-14034101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional