Healthcare Provider Details

I. General information

NPI: 1710421045
Provider Name (Legal Business Name): CAROLINE DYKSTRA PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2016
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1156 W LAKE COOK RD
BUFFALO GROVE IL
60089
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 847-520-7264
  • Fax: 847-520-7290
Mailing address:
  • Phone: 630-575-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22727
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070024020
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: