Provider Demographics
NPI:1871674978
Name:VAN SICLEN, ROBERT CORNELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:CORNELL
Last Name:VAN SICLEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:277 COON RAPIDS BOULEVARD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5843
Mailing Address - Country:US
Mailing Address - Phone:763-717-4979
Mailing Address - Fax:763-717-4954
Practice Address - Street 1:277 COON RAPIDS BLVD NW
Practice Address - Street 2:SUITE 308
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5843
Practice Address - Country:US
Practice Address - Phone:763-717-4979
Practice Address - Fax:763-717-4954
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP2775103TB0200X, 103TC0700X, 103TC2200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3K444VAOtherBLUE CROSS BLUE SHIELD
MN108029OtherUCARE PROVIDER NUMBER
MN61-20060OtherUNITED BEHAVIORAL HEALTH