Provider Demographics
NPI:1205987005
Name:VAN NUS, CYNTHIA L (LISW)
Entity type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:L
Last Name:VAN NUS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MAIN ST
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:HILTON HEAD ISL
Mailing Address - State:SC
Mailing Address - Zip Code:29926
Mailing Address - Country:US
Mailing Address - Phone:843-342-6005
Mailing Address - Fax:843-342-6008
Practice Address - Street 1:1000 MAIN ST
Practice Address - Street 2:SUITE 100B
Practice Address - City:HILTON HEAD ISL
Practice Address - State:SC
Practice Address - Zip Code:29926
Practice Address - Country:US
Practice Address - Phone:843-342-6005
Practice Address - Fax:843-342-6008
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6267104100000X
MI68010031541041C0700X
MI4101005521106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q320910281Medicare ID - Type Unspecified