Provider Demographics
NPI:1790106185
Name:VAN DYKE, TRACEY J (MA S/T)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:J
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:MA S/T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4823 N ROYAL ATLANTA DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3806
Mailing Address - Country:US
Mailing Address - Phone:770-939-2121
Mailing Address - Fax:
Practice Address - Street 1:4823 N ROYAL ATLANTA DR
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3806
Practice Address - Country:US
Practice Address - Phone:770-939-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health