Healthcare Provider Details

I. General information

NPI: 1932340304
Provider Name (Legal Business Name): TRISHA DAWN DYKEMA LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2009
Last Update Date: 03/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 N UNION BLVD STE 100
COLORADO SPRINGS CO
80918-4035
US

IV. Provider business mailing address

4905 N UNION BLVD STE 100
COLORADO SPRINGS CO
80918-4035
US

V. Phone/Fax

Practice location:
  • Phone: 719-598-3055
  • Fax:
Mailing address:
  • Phone: 719-598-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number708527
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: