Provider Demographics
NPI:1306561972
Name:VAN VLACK, MEGAN KAY (LMFT, LPCC)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:KAY
Last Name:VAN VLACK
Suffix:
Gender:F
Credentials:LMFT, LPCC
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:KAY
Other - Last Name:ELLIS VAN VLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMFT
Mailing Address - Street 1:5725 OAK GROVE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1244
Mailing Address - Country:US
Mailing Address - Phone:925-335-6561
Mailing Address - Fax:
Practice Address - Street 1:5725 OAK GROVE AVE STE 1
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1244
Practice Address - Country:US
Practice Address - Phone:925-335-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14946101YP2500X
CA134203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional