Healthcare Provider Details

I. General information

NPI: 1104963438
Provider Name (Legal Business Name): CHRISTOPHER VAN DYKE MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 COMMERCE AVE
CULLMAN AL
35055-6151
US

IV. Provider business mailing address

1007 MAPLE DR NW
CULLMAN AL
35055-2317
US

V. Phone/Fax

Practice location:
  • Phone: 256-734-4688
  • Fax: 256-736-5638
Mailing address:
  • Phone: 256-739-3409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier51507586VAN
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: