Provider Demographics
NPI:1497457584
Name:VAN DINTER, MAX
Entity Type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:VAN DINTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 BRUNSWICK DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-7343
Mailing Address - Country:US
Mailing Address - Phone:719-321-1650
Mailing Address - Fax:
Practice Address - Street 1:8415 EXPLORER DR STE 130
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-1034
Practice Address - Country:US
Practice Address - Phone:719-900-5690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-23-262820106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician