MEDICARE: MARTIN VAN DYKE POOL LCSW

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	1041C0700X	Clinical Social Worker	0904008797	VA

General Provider Information

NPI Number	:	1710990338
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN VAN DYKE POOL LCSW

Provider Business Mailing Address
First Line	:	83 BOSTON HILL RD
Second Line	:
City	:	CARTERSVILLE
State	:	VA
Zip	:	23027-9716
Country	:	US
Telephone Number	:	434-409-2596
Fax Number	:

Provider Business Practice Location Address
First Line	:	83 BOSTON HILL RD
Second Line	:
City	:	CARTERSVILLE
State	:	VA
Zip	:	23027-9716
Country	:	US
Telephone Number	:	434-409-2596
Fax Number	:

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	04/24/2015

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