Provider Demographics
NPI:1831777101
Name:VANDYCK, ASHLEY (LPC-IT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:VANDYCK
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:VAN DYCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC-IT
Mailing Address - Street 1:424 S MONROE AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-4054
Mailing Address - Country:US
Mailing Address - Phone:920-445-0170
Mailing Address - Fax:920-445-0174
Practice Address - Street 1:424 S MONROE AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4054
Practice Address - Country:US
Practice Address - Phone:920-445-0170
Practice Address - Fax:920-445-0174
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4928-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health