Provider Demographics
NPI:1992009633
Name:VANDYKE, BRIAN HOWARD
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:HOWARD
Last Name:VANDYKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 MAIN ST STE 500
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2972
Mailing Address - Country:US
Mailing Address - Phone:360-695-1014
Mailing Address - Fax:360-750-1374
Practice Address - Street 1:1104 MAIN ST STE 500
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2972
Practice Address - Country:US
Practice Address - Phone:360-695-1014
Practice Address - Fax:360-750-1374
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60154427101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health