Basic Information
| Provider Information | |||||||||
| NPI: | 1497290431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DYKE | ||||||||
| FirstName: | AARON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | QMHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1199 B AVE | ||||||||
| Address2: | |||||||||
| City: | TERREBONNE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977609440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1199 B AVE | ||||||||
| Address2: | |||||||||
| City: | TERREBONNE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977609440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413235330 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2016 | ||||||||
| LastUpdateDate: | 12/29/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 283234 | 05 | OR | MEDICAID |