Provider Demographics
NPI:1588179840
Name:VAN WYK, LAURA ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:VAN WYK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 E ELIZABETH AVE APT 201
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-3163
Mailing Address - Country:US
Mailing Address - Phone:908-251-3399
Mailing Address - Fax:
Practice Address - Street 1:2090 ADAM CLAYTON POWELL JR BLVD FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4941
Practice Address - Country:US
Practice Address - Phone:212-553-6751
Practice Address - Fax:212-222-2318
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0860041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical