Healthcare Provider Details

I. General information

NPI: 1972855906
Provider Name (Legal Business Name): JULIE A DYKSTRA RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W BLUE HERON BLVD
RIVIERA BEACH FL
33404-5003
US

IV. Provider business mailing address

2001 W BLUE HERON BLVD
RIVIERA BEACH FL
33404-5003
US

V. Phone/Fax

Practice location:
  • Phone: 561-841-3500
  • Fax:
Mailing address:
  • Phone: 561-841-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 8505
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: