Provider Demographics
NPI:1376616086
Name:VANDYKE, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31584 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1805
Mailing Address - Country:US
Mailing Address - Phone:734-266-1335
Mailing Address - Fax:734-427-0060
Practice Address - Street 1:31584 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1805
Practice Address - Country:US
Practice Address - Phone:734-266-1335
Practice Address - Fax:734-427-0060
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007473101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional