Healthcare Provider Details

I. General information

NPI: 1639852494
Provider Name (Legal Business Name): DYLAN BLAKE VANDEVER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S 48TH STREET STE 101
ROGERS AR
72758
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-202-8040
  • Fax: 870-351-4095
Mailing address:
  • Phone: 479-750-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA230714
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: