Healthcare Provider Details

I. General information

NPI: 1427302710
Provider Name (Legal Business Name): HEIDI HRISTINE DYK BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1014 MAIN ST
VANCOUVER WA
98660-3151
US

IV. Provider business mailing address

1014 MAIN ST
VANCOUVER WA
98660-3151
US

V. Phone/Fax

Practice location:
  • Phone: 360-910-7199
  • Fax: 360-750-1374
Mailing address:
  • Phone: 360-910-7199
  • Fax: 360-750-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60304149
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: