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NPI Code Detail

MEDICARE: BROCK VAN DYKE

MEDICARE: BROCK VAN DYKE
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
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1609477561
Entity Type Code : Individual
Provider Name (Legal Business Name) : BROCK VAN DYKE
Provider Business Mailing Address
First Line : PO BOX 740780
Second Line :
City : ATLANTA
State : GA
Zip : 30374-0780
Country : US
Telephone Number : 855-223-7123
Fax Number :
Provider Business Practice Location Address
First Line : 10015 LAKEWOOD DR SW
Second Line :
City : LAKEWOOD
State : WA
Zip : 98499-3838
Country : US
Telephone Number : 855-223-7123
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/05/2020
Last Update Date : 03/04/2026

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Directions to “ BROCK VAN DYKE ” Practice Location

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