Provider Demographics
NPI:1336681352
Name:VAN FLEET, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:VAN FLEET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 OPAL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-7633
Mailing Address - Country:US
Mailing Address - Phone:240-575-8877
Mailing Address - Fax:
Practice Address - Street 1:704 EMMET ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2910
Practice Address - Country:US
Practice Address - Phone:231-347-5511
Practice Address - Fax:231-347-5422
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)