Provider Demographics
NPI:1447963707
Name:VANDYKEN, MAXIMUS ALEXANDER
Entity type:Individual
Prefix:MR
First Name:MAXIMUS
Middle Name:ALEXANDER
Last Name:VANDYKEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MATELYN
Other - Middle Name:
Other - Last Name:VANDYKEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2925 BRETON RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-1745
Mailing Address - Country:US
Mailing Address - Phone:616-243-4336
Mailing Address - Fax:
Practice Address - Street 1:2925 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1745
Practice Address - Country:US
Practice Address - Phone:616-243-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician