Provider Demographics
NPI:1356787345
Name:VANDYKE-VELASQUEZ, SARAH ANN (PHD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:ANN
Last Name:VANDYKE-VELASQUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:SARAH
Other - Middle Name:ANN
Other - Last Name:VAN DYKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:275 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2531
Practice Address - Country:US
Practice Address - Phone:616-267-7401
Practice Address - Fax:616-267-7594
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014869103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460915Medicare PIN