Provider Demographics
NPI:1104403104
Name:VAN DYKE, ANITA JOAN (LPC)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:JOAN
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9425 ELDERBERRY RD # 9425
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-4365
Mailing Address - Country:US
Mailing Address - Phone:319-329-5149
Mailing Address - Fax:
Practice Address - Street 1:9425 ELDERBERRY RD # 9425
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-4365
Practice Address - Country:US
Practice Address - Phone:319-329-5149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7916-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional