Provider Demographics
NPI:1457672164
Name:VANSICE, MICHAEL DEAN (MSW, LISW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DEAN
Last Name:VANSICE
Suffix:
Gender:M
Credentials:MSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 SIRINGO RONDO E
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-5017
Mailing Address - Country:US
Mailing Address - Phone:505-603-4369
Mailing Address - Fax:
Practice Address - Street 1:2960 RODEO PARK DR W
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6351
Practice Address - Country:US
Practice Address - Phone:505-986-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-070131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical