Provider Demographics
NPI:1508483926
Name:VAN CAMP, MYLES GODSHALL
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:GODSHALL
Last Name:VAN CAMP
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 1:1119 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3523
Mailing Address - Country:US
Mailing Address - Phone:630-542-8815
Mailing Address - Fax:
Practice Address - Street 1:45 S PARK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6282
Practice Address - Country:US
Practice Address - Phone:630-423-5935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health