Healthcare Provider Details

I. General information

NPI: 1164099115
Provider Name (Legal Business Name): MADISON MARIE VANDYKE LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9315 TELEGRAPH RD
REDFORD MI
48239-1260
US

IV. Provider business mailing address

20882 ORCHARD LAKE RD
FARMINGTON HILLS MI
48336-5223
US

V. Phone/Fax

Practice location:
  • Phone: 313-450-4500
  • Fax:
Mailing address:
  • Phone: 248-819-6374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801109889
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: