Provider Demographics
NPI:1780655407
Name:VAN DER VEUR, FREDERICK (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:
Last Name:VAN DER VEUR
Suffix:
Gender:M
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:PO BOX 901173
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84090-1173
Mailing Address - Country:US
Mailing Address - Phone:801-580-3905
Mailing Address - Fax:
Practice Address - Street 1:1020 SOUTH MAIN STREET
Practice Address - Street 2:242
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101
Practice Address - Country:US
Practice Address - Phone:801-539-7093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11635935011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1780655407Medicaid
UT11635935003001OtherREGENCE BCBS
UT1163593501OtherLSCW LICENSE #
UTP00204131OtherRAILROAD MEDICARE
UT11635935003001OtherREGENCE BCBS
UTP85287Medicare UPIN
UTU00075206Medicare PIN