Provider Demographics
NPI:1558139790
Name:VAN WYK, DYLAN CADE
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:CADE
Last Name:VAN WYK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 CHERRY ST SE APT 610
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4762
Mailing Address - Country:US
Mailing Address - Phone:269-365-1731
Mailing Address - Fax:
Practice Address - Street 1:1550 E BELTLINE AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4301
Practice Address - Country:US
Practice Address - Phone:616-765-8585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851117690APP23104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker