Healthcare Provider Details

I. General information

NPI: 1629687066
Provider Name (Legal Business Name): SAMANTHA DYKE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6044 PARKSIDE MEADOW DR
TAMPA FL
33625-5757
US

IV. Provider business mailing address

6044 PARKSIDE MEADOW DR
TAMPA FL
33625-5757
US

V. Phone/Fax

Practice location:
  • Phone: 610-291-2441
  • Fax:
Mailing address:
  • Phone: 610-291-2441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH17388
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: