Healthcare Provider Details

I. General information

NPI: 1548581739
Provider Name (Legal Business Name): BECKY A DYKSTRA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6003 E 41ST ST N
BEL AIRE KS
67220-3866
US

IV. Provider business mailing address

6003 E 41ST ST N
BEL AIRE KS
67220-3866
US

V. Phone/Fax

Practice location:
  • Phone: 316-744-9252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-01627
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: