Provider Demographics
NPI:1568745313
Name:VAN DEILEN, VICKI L (M ED, LPC)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:L
Last Name:VAN DEILEN
Suffix:
Gender:F
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-7149
Mailing Address - Country:US
Mailing Address - Phone:419-351-5111
Mailing Address - Fax:828-837-8410
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-7149
Practice Address - Country:US
Practice Address - Phone:419-351-5111
Practice Address - Fax:828-837-8410
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006465101YM0800X, 101YP2500X
OHC0900423101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health