Provider Demographics
NPI:1952583346
Name:VANDYKE, MAUREEN JEANNETTE
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:JEANNETTE
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-1344
Mailing Address - Country:US
Mailing Address - Phone:304-737-3481
Mailing Address - Fax:304-737-3480
Practice Address - Street 1:1201 PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-1344
Practice Address - Country:US
Practice Address - Phone:304-737-3481
Practice Address - Fax:304-737-3480
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV9311103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9205014000Medicaid