Healthcare Provider Details

I. General information

NPI: 1548188766
Provider Name (Legal Business Name): KEVIN JAMES DYKSTRA MDIV, MA, LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

233 FULTON ST E
GRAND RAPIDS MI
49503-3200
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-9244
  • Fax: 616-327-6333
Mailing address:
  • Phone: 616-228-9244
  • Fax: 616-327-6333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451025164
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: