Provider Demographics
NPI:1730706482
Name:VANDYKE, KELSEY (OTR/L)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:VANDYKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 KATELAND ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-3204
Mailing Address - Country:US
Mailing Address - Phone:254-223-3914
Mailing Address - Fax:
Practice Address - Street 1:505 KANSAS CITY ST STE 3
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-3673
Practice Address - Country:US
Practice Address - Phone:605-222-7336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1168225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist