Provider Demographics
NPI:1356408785
Name:VANDYCK, GERDA BERNICE (MSW)
Entity type:Individual
Prefix:
First Name:GERDA
Middle Name:BERNICE
Last Name:VANDYCK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 JAMES ST
Mailing Address - Street 2:7A
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2610
Mailing Address - Country:US
Mailing Address - Phone:315-422-8099
Mailing Address - Fax:
Practice Address - Street 1:530 OAK ST
Practice Address - Street 2:5
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1652
Practice Address - Country:US
Practice Address - Phone:315-250-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPRO16253-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55150BMedicare ID - Type Unspecified