| Doctor Name: | KEVIN VAN LAEKEN |
| NPI Number: | 1104299734 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | BCBA |
| License Number: | LEP3635 |
| Business Practice Address: | 809 Mccloud Ave Mount Shasta, CA - 960679603 |
| Business Phone Number: | 5302272883 |
| Business Fax Number: | |
| Mailing Address: | 809 Mccloud Ave, MOUNT SHASTA |
| State: | CA |
| Postal Code: | 960679603 |
| Phone Number: | 5302272883 |
| Fax Number: | |
| NPI Enumeration Date: | 11/04/2015 |
| NPI Last Update Date: | 11/04/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TS0200X |
| License Number: | LEP3635 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |