Provider Demographics
NPI:1689276263
Name:VAN DER LAAR, KIRA SUE (LISW)
Entity type:Individual
Prefix:
First Name:KIRA
Middle Name:SUE
Last Name:VAN DER LAAR
Suffix:
Gender:
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:GIBSONBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43431-1221
Mailing Address - Country:US
Mailing Address - Phone:567-201-6450
Mailing Address - Fax:
Practice Address - Street 1:430 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9734
Practice Address - Country:US
Practice Address - Phone:844-534-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-10
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1901397101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health