Basic Information
| Provider Information | |||||||||
| NPI: | 1467627869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDYK | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4860 ROBB ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | WHEAT RIDGE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800332162 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889486789 | ||||||||
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| Practice Location | |||||||||
| Address1: | 606 WALL ST | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463832513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2194643612 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 08/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34004775A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PO20008531F | 05 | IN | MEDICAID |