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General NPI Number Information
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NPI Number | 1023123767
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Entity Type | Individual
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Provider Name | WILLIS T VAN DYNE PSY D
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Gender | Male
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Dates
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Enumeration Date | 08/21/2006
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Last Update Date | 04/15/2008
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Provider Practice Location Address
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Address Line | 41 2ND ST
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City | TROY
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State | NY
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Zip | 12180-3928
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Country | US
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Telephone | 518-272-0506
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Fax |
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Provider Business Mailing Address
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Address Line | 41 2ND ST
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City | TROY
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State | NY
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Zip | 12180-3928
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Country | US
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Telephone | 518-272-0506
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 006790
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License Number State | NY
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