Provider Demographics
NPI:1285720706
Name:VAN DYKE, NANCY WARREN (LCSW)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:WARREN
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MAIN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SEA CLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:11579-1330
Mailing Address - Country:US
Mailing Address - Phone:516-759-1216
Mailing Address - Fax:516-674-2115
Practice Address - Street 1:65 MAIN AVENUE
Practice Address - Street 2:
Practice Address - City:SEA CLIFF
Practice Address - State:NY
Practice Address - Zip Code:11579-1330
Practice Address - Country:US
Practice Address - Phone:516-759-1216
Practice Address - Fax:516-674-2115
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0077611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN17311Medicare ID - Type Unspecified