Provider Demographics
NPI:1619241601
Name:DALE, VANDER J JR (LMSW, LCAC, CATC-IV,)
Entity Type:Individual
Prefix:
First Name:VANDER
Middle Name:J
Last Name:DALE
Suffix:JR
Gender:M
Credentials:LMSW, LCAC, CATC-IV,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 RIVER AVENUE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810
Mailing Address - Country:US
Mailing Address - Phone:562-826-8470
Mailing Address - Fax:562-826-8485
Practice Address - Street 1:2090 RIVER AVENUE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90810
Practice Address - Country:US
Practice Address - Phone:562-826-8470
Practice Address - Fax:562-826-8485
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001320A101Y00000X
TNLSW0000008307104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor