Provider Demographics
NPI:1598086076
Name:VANSLYKE, MICHAEL ALLEN (BA, LISAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLEN
Last Name:VANSLYKE
Suffix:
Gender:M
Credentials:BA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6540 N CHOLLA LN
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85194-6896
Mailing Address - Country:US
Mailing Address - Phone:520-836-1675
Mailing Address - Fax:
Practice Address - Street 1:6540 N CHOLLA LN
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85194-6896
Practice Address - Country:US
Practice Address - Phone:520-836-1675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10197101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)