Healthcare Provider Details

I. General information

NPI: 1154704716
Provider Name (Legal Business Name): NATHAN VAN DYKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S 700 E STE 102
SALT LAKE CITY UT
84105-2125
US

IV. Provider business mailing address

433 W 2ND AVE
MIDVALE UT
84047-7307
US

V. Phone/Fax

Practice location:
  • Phone: 801-448-7577
  • Fax:
Mailing address:
  • Phone: 801-577-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9148081-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9148081-6006
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: