Provider Demographics
NPI:1396093399
Name:DYCK, WENDELL RAYMOND (LMP, JD)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:RAYMOND
Last Name:DYCK
Suffix:
Gender:M
Credentials:LMP, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 RAINIER AVE S
Mailing Address - Street 2:UNIT C
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98118-1744
Mailing Address - Country:US
Mailing Address - Phone:206-660-9139
Mailing Address - Fax:
Practice Address - Street 1:4906 RAINIER AVE S
Practice Address - Street 2:UNIT D
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-1744
Practice Address - Country:US
Practice Address - Phone:206-660-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA22065225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist