Provider Demographics
NPI:1659382786
Name:VANDYKE, BILLY WAYNE (PTA)
Entity Type:Individual
Prefix:MR
First Name:BILLY
Middle Name:WAYNE
Last Name:VANDYKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 DICKENSON ST APT 1
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-3257
Mailing Address - Country:US
Mailing Address - Phone:304-235-4300
Mailing Address - Fax:304-235-0176
Practice Address - Street 1:54 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3508
Practice Address - Country:US
Practice Address - Phone:304-235-4300
Practice Address - Fax:304-235-0176
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV000652225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant