1619241601 NPI number — VANDER J. DALE JR. LMSW, LCAC, CATC-IV,

Table of content: VANDER J. DALE JR. LMSW, LCAC, CATC-IV, (NPI 1619241601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619241601 NPI number — VANDER J. DALE JR. LMSW, LCAC, CATC-IV,

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DALE
Provider First Name:
VANDER
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
LMSW, LCAC, CATC-IV,
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619241601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2090 RIVER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90810
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-826-8470
Provider Business Mailing Address Fax Number:
562-826-8485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2090 RIVER AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90810
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-826-8470
Provider Business Practice Location Address Fax Number:
562-826-8485
Provider Enumeration Date:
03/08/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  87001320A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: LSW0000008307 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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