Basic Information
| Provider Information | |||||||||
| NPI: | 1730469701 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDYKE | ||||||||
| FirstName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 NORTHGATE DR | ||||||||
| Address2: | FAMILY SERVICE AGENCY OF MARIN | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033680 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 NORTHGATE DR | ||||||||
| Address2: | FAMILY SERVICE AGENCY OF MARIN | ||||||||
| City: | SAN RAFAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949033680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154915700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.