MEDICARE: MR. BRIAN LEE DYKE LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	302794	MN

General Provider Information

NPI Number	:	1144615626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN LEE DYKE LADC

Provider Business Mailing Address
First Line	:	1828 JEFFERSON ST NE STE C
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4427
Country	:	US
Telephone Number	:	612-362-8931
Fax Number	:

Provider Business Practice Location Address
First Line	:	1828 JEFFERSON ST NE STE C
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-4427
Country	:	US
Telephone Number	:	612-362-8931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2015
Last Update Date	:	09/29/2023

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