Provider Demographics
NPI:1427409572
Name:VANDYKE, SUSANNAH LYNN (MA)
Entity Type:Individual
Prefix:
First Name:SUSANNAH
Middle Name:LYNN
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5035 DEL MONTE AVE
Mailing Address - Street 2:8
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92107-3235
Mailing Address - Country:US
Mailing Address - Phone:708-341-8273
Mailing Address - Fax:
Practice Address - Street 1:3821 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3019
Practice Address - Country:US
Practice Address - Phone:708-341-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84859106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist