Provider Demographics
NPI:1437166162
Name:VAN SICKLE, DONALD M JR (LPCC)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:VAN SICKLE
Suffix:JR
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4751 SUNDANCE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9313
Mailing Address - Country:US
Mailing Address - Phone:505-326-1074
Mailing Address - Fax:
Practice Address - Street 1:701 W APACHE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5511
Practice Address - Country:US
Practice Address - Phone:505-327-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0183101YM0800X
NM224-044103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool