Provider Demographics
NPI:1396712238
Name:VAN DYKE, ANNE (PHD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4171 NATHAN W
Mailing Address - Street 2:
Mailing Address - City:STERLING HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-2650
Mailing Address - Country:US
Mailing Address - Phone:248-660-5034
Mailing Address - Fax:
Practice Address - Street 1:4171 NATHAN W
Practice Address - Street 2:
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48310-2650
Practice Address - Country:US
Practice Address - Phone:248-660-5034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005409103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F371350OtherBCBSM
MI0F37135004Medicare ID - Type Unspecified
MI680F371350OtherBCBSM