Healthcare Provider Details

I. General information

NPI: 1891131785
Provider Name (Legal Business Name): MICHAEL DYKES LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2013
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 BOULEVARD NE
ATLANTA GA
30312-1216
US

IV. Provider business mailing address

PO BOX 8472 ATLANTA GA
ATLANTA GA
31106-0472
US

V. Phone/Fax

Practice location:
  • Phone: 770-873-1929
  • Fax:
Mailing address:
  • Phone: 770-873-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: