Provider Demographics
NPI:1710756937
Name:VAN DYNE, KATHRYN RUTH
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:RUTH
Last Name:VAN DYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355-2869
Mailing Address - Country:US
Mailing Address - Phone:541-451-6388
Mailing Address - Fax:541-812-2056
Practice Address - Street 1:111 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355-2869
Practice Address - Country:US
Practice Address - Phone:541-451-6388
Practice Address - Fax:541-812-2056
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)