Provider Demographics
NPI:1700013422
Name:VANDER LEY, MARK L (MA, LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:VANDER LEY
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62305-6514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:822 STATE ST
Practice Address - Street 2:SUITE # 9E
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-4961
Practice Address - Country:US
Practice Address - Phone:217-231-1413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-20
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009009736101YP2500X
IL180008138101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional