Provider Demographics
NPI:1922106970
Name:VANDER POL, COLLIN J (LCSW)
Entity Type:Individual
Prefix:MR
First Name:COLLIN
Middle Name:J
Last Name:VANDER POL
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 1693
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0029
Mailing Address - Country:US
Mailing Address - Phone:706-867-0566
Mailing Address - Fax:706-867-6859
Practice Address - Street 1:81 CROWN MOUNTAIN PL
Practice Address - Street 2:SUITE A-300
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1627
Practice Address - Country:US
Practice Address - Phone:706-867-0566
Practice Address - Fax:706-867-6859
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0035701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA448982378AMedicaid
GA448982378BMedicaid
GAQ66714Medicare UPIN
GA80BBGFZMedicare ID - Type UnspecifiedMEDICARE PROVIDER ID#