Provider Demographics
NPI:1619410412
Name:NOAH, VAN DYKE KOFI
Entity Type:Individual
Prefix:MR
First Name:VAN DYKE
Middle Name:KOFI
Last Name:NOAH
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 1:4836 SAFARI PASS
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2663
Mailing Address - Country:US
Mailing Address - Phone:952-846-8047
Mailing Address - Fax:
Practice Address - Street 1:4836 SAFARI PASS
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2663
Practice Address - Country:US
Practice Address - Phone:952-846-8047
Practice Address - Fax:651-452-2698
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1083493-1-HCBS106S00000X
1083493-1-HCBS385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1081688-1-AFCOtherADULT FOSTER CARE