Healthcare Provider Details

I. General information

NPI: 1750669818
Provider Name (Legal Business Name): JANICE LYNNE DYKSTRA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2011
Last Update Date: 07/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 RAYBROOK ST SE SUITE 104A
GRAND RAPIDS MI
49546-7717
US

IV. Provider business mailing address

2020 RAYBROOK ST SE SUITE 104A
GRAND RAPIDS MI
49546-7717
US

V. Phone/Fax

Practice location:
  • Phone: 616-560-0424
  • Fax:
Mailing address:
  • Phone: 616-560-0424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: