MEDICARE: KIRSTEN ROSE VAN DYKE MS, TIC-C

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	103TC1900X	Counseling Psychologist		WI

General Provider Information

NPI Number	:	1912714999
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIRSTEN ROSE VAN DYKE MS, TIC-C

Provider Business Mailing Address
First Line	:	2258 RED OAK DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1784
Country	:	US
Telephone Number	:	920-664-5989
Fax Number	:

Provider Business Practice Location Address
First Line	:	2258 RED OAK DR
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54304-1784
Country	:	US
Telephone Number	:	920-664-5989
Fax Number	:

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

Provider Enumeration Date	:	12/13/2024
Last Update Date	:	12/13/2024

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