Provider Demographics
NPI:1184177131
Name:DYKE, MARY JANE (LCSW)
Entity type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:DYKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MJ
Other - Middle Name:
Other - Last Name:DYKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:310 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2834
Mailing Address - Country:US
Mailing Address - Phone:575-297-0171
Mailing Address - Fax:
Practice Address - Street 1:428 MARR ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3381
Practice Address - Country:US
Practice Address - Phone:575-894-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM09548104100000X
NMC-105911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker