Healthcare Provider Details

I. General information

NPI: 1710654041
Provider Name (Legal Business Name): MEGAN LYNN VANDYKE LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2021
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E STE 526
GRAND RAPIDS MI
49503-3269
US

IV. Provider business mailing address

233 FULTON ST E STE 526
GRAND RAPIDS MI
49503-3269
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax: 616-805-3661
Mailing address:
  • Phone: 616-805-3660
  • Fax: 616-805-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451019688
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: