Provider Demographics
NPI:1780041244
Name:VAN DYCK, DANIEL WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:WILLIAM
Last Name:VAN DYCK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:MR
Other - First Name:DANIEL
Other - Middle Name:WILLIAM
Other - Last Name:VAN DYCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:118 JERRY SELBY DR
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-4734
Mailing Address - Country:US
Mailing Address - Phone:870-364-1534
Mailing Address - Fax:
Practice Address - Street 1:118 JERRY SELBY DR
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-4734
Practice Address - Country:US
Practice Address - Phone:870-364-1534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 2602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility