Provider Demographics
NPI:1376774273
Name:VANDE STREEK, HARLEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:HARLEY
Middle Name:
Last Name:VANDE STREEK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 LONETREE BLVD STE 223
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-3796
Mailing Address - Country:US
Mailing Address - Phone:916-276-1515
Mailing Address - Fax:
Practice Address - Street 1:5701 LONETREE BLVD STE 223
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-3796
Practice Address - Country:US
Practice Address - Phone:916-276-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22597103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical