MEDICARE: ADRIAAN FRANCOIS VAN WYK LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	40089	CA

General Provider Information

NPI Number	:	1245399088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADRIAAN FRANCOIS VAN WYK LMFT

Provider Business Mailing Address
First Line	:	PO BOX 745
Second Line	:
City	:	COBB
State	:	CA
Zip	:	95426-0745
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9667 HIGHWAY 29
Second Line	:	SUITE 102
City	:	LOWER LAKE
State	:	CA
Zip	:	95457
Country	:	US
Telephone Number	:	707-295-6019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2006
Last Update Date	:	10/10/2018

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