Provider Demographics
NPI:1619608049
Name:VANDYKE, ARDELLA (LICSW)
Entity Type:Individual
Prefix:
First Name:ARDELLA
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14190 CALL OF THE WILD DR
Mailing Address - Street 2:
Mailing Address - City:AKELEY
Mailing Address - State:MN
Mailing Address - Zip Code:56433-2606
Mailing Address - Country:US
Mailing Address - Phone:673-412-8319
Mailing Address - Fax:
Practice Address - Street 1:14090 CALL OF THE WILD DR
Practice Address - Street 2:
Practice Address - City:AKELEY
Practice Address - State:MN
Practice Address - Zip Code:56433
Practice Address - Country:US
Practice Address - Phone:763-412-8319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN156831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical