Basic Information
| Provider Information | |||||||||
| NPI: | 1164099115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDYKE | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20882 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483365223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488196374 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9315 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134504500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2021 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801109889 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.