Basic Information
| Provider Information | |||||||||
| NPI: | 1992009633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDYKE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1104 MAIN ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986602972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951014 | ||||||||
| FaxNumber: | 3607501374 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 MAIN ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986602972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606951014 | ||||||||
| FaxNumber: | 3607501374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2011 | ||||||||
| LastUpdateDate: | 01/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CG60154427 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.