Provider Demographics
NPI:1427886480
Name:VAN DYKE, TAMMY (MC61565562)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:U
Credentials:MC61565562
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5049 VAARA DR
Mailing Address - Street 2:
Mailing Address - City:BOW
Mailing Address - State:WA
Mailing Address - Zip Code:98232-9379
Mailing Address - Country:US
Mailing Address - Phone:360-770-1674
Mailing Address - Fax:
Practice Address - Street 1:200 N CHELAN AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2105
Practice Address - Country:US
Practice Address - Phone:509-888-4866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61565562101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health