Healthcare Provider Details

I. General information

NPI: 1932589074
Provider Name (Legal Business Name): MARK DYKE LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4124 56TH ST SW STE 4
WYOMING MI
49418-9494
US

IV. Provider business mailing address

2295 VAN BUREN ST
HUDSONVILLE MI
49426-6400
US

V. Phone/Fax

Practice location:
  • Phone: 616-222-0631
  • Fax:
Mailing address:
  • Phone: 616-401-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401223230
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: