Provider Demographics
NPI:1043059959
Name:VAN DYKE, AMY (MED)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 VINEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1432
Mailing Address - Country:US
Mailing Address - Phone:440-925-5583
Mailing Address - Fax:
Practice Address - Street 1:157 VINEWOOD DR
Practice Address - Street 2:
Practice Address - City:AVON LAKE
Practice Address - State:OH
Practice Address - Zip Code:44012-1432
Practice Address - Country:US
Practice Address - Phone:440-925-5583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAMV-0113-0101103TS0200X
103TS0200X
OHOH3027669103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool