MEDICARE: ANNE VAN DYKE PH.D.

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	103TC0700X	Clinical Psychologist	6301005409	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680F371350	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1396712238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE VAN DYKE PH.D.

Provider Business Mailing Address
First Line	:	4171 NATHAN W
Second Line	:
City	:	STERLING HTS
State	:	MI
Zip	:	48310-2650
Country	:	US
Telephone Number	:	248-660-5034
Fax Number	:

Provider Business Practice Location Address
First Line	:	4171 NATHAN W
Second Line	:
City	:	STERLING HTS
State	:	MI
Zip	:	48310-2650
Country	:	US
Telephone Number	:	248-660-5034
Fax Number	:

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

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	10/29/2024

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