Provider Demographics
NPI:1487703625
Name:VANDYKE, DALE F (LCSW)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:F
Last Name:VANDYKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 S 76TH ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-4361
Mailing Address - Country:US
Mailing Address - Phone:414-325-7741
Mailing Address - Fax:414-325-7753
Practice Address - Street 1:4848 S 76TH ST
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4361
Practice Address - Country:US
Practice Address - Phone:414-325-7741
Practice Address - Fax:414-325-7753
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12701101YA0400X
WI2154-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39585200Medicaid