Provider Demographics
NPI:1508958067
Name:VAN DYKE, MARK ANTHONY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANTHONY
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 N CRAYCROFT RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2802
Mailing Address - Country:US
Mailing Address - Phone:520-546-4452
Mailing Address - Fax:520-546-4494
Practice Address - Street 1:2250 N CRAYCROFT RD
Practice Address - Street 2:SUITE 250
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2802
Practice Address - Country:US
Practice Address - Phone:520-546-4452
Practice Address - Fax:520-546-4494
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-35371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ883729OtherAHCCCS
AZ883729OtherAHCCCS