Healthcare Provider Details

I. General information

NPI: 1093532541
Provider Name (Legal Business Name): CHRIS DYKHUISEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12799 N KERN RD
SYRACUSE IN
46567-1499
US

IV. Provider business mailing address

19474 OZINGA DR
NEW PARIS IN
46553-9666
US

V. Phone/Fax

Practice location:
  • Phone: 574-457-4484
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1616361
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: