Healthcare Provider Details

I. General information

NPI: 1316216732
Provider Name (Legal Business Name): ANDREW D VANDYKE LPC, CGP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 W CUCHARRAS ST
COLORADO SPRINGS CO
80904-4336
US

IV. Provider business mailing address

1118 W CUCHARRAS ST
COLORADO SPRINGS CO
80904-4336
US

V. Phone/Fax

Practice location:
  • Phone: 719-659-6228
  • Fax:
Mailing address:
  • Phone: 719-659-6228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-6331
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-6331
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: