Healthcare Provider Details

I. General information

NPI: 1598677999
Provider Name (Legal Business Name): ELISABETH DYKSHORN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISABETH PETERSON

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12035 UNIVERSITY AVE STE 202
CLIVE IA
50325-8264
US

IV. Provider business mailing address

12035 UNIVERSITY AVE STE 202
CLIVE IA
50325-8264
US

V. Phone/Fax

Practice location:
  • Phone: 515-650-2627
  • Fax:
Mailing address:
  • Phone: 515-650-2627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number130931
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: