| Doctor Name: | MR. EDGAR CARL DE VAN |
| NPI Number: | 1215139019 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | CAC II |
| License Number: | 6541 |
| Business Practice Address: | 615 Russell Ave Walsenburg, CO - 810892127 |
| Business Phone Number: | 7197382076 |
| Business Fax Number: | |
| Mailing Address: | 206 W 3rd St, WALSENBURG |
| State: | CO |
| Postal Code: | 810891904 |
| Phone Number: | 7197381082 |
| Fax Number: | |
| NPI Enumeration Date: | 06/04/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | 6541 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |