Provider Demographics
NPI:1215139019
Name:DE VAN, EDGAR CARL III (CAC II)
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:CARL
Last Name:DE VAN
Suffix:III
Gender:M
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WALSENBURG
Mailing Address - State:CO
Mailing Address - Zip Code:81089-1904
Mailing Address - Country:US
Mailing Address - Phone:719-738-1082
Mailing Address - Fax:
Practice Address - Street 1:615 RUSSELL AVE
Practice Address - Street 2:
Practice Address - City:WALSENBURG
Practice Address - State:CO
Practice Address - Zip Code:81089-2127
Practice Address - Country:US
Practice Address - Phone:719-738-2076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6541101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)