Provider Demographics
NPI:1386729994
Name:VAN DAM, MICHAEL LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:VAN DAM
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 1:94 E PAGES LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2216
Mailing Address - Country:US
Mailing Address - Phone:801-294-0578
Mailing Address - Fax:
Practice Address - Street 1:94 E PAGES LN
Practice Address - Street 2:SUITE A
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-2216
Practice Address - Country:US
Practice Address - Phone:801-294-0578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5199130-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical