Healthcare Provider Details

I. General information

NPI: 1487046579
Provider Name (Legal Business Name): ASHLEY RENEE DYKSTRA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 12/01/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5020 E BELTLINE AVE NE SUITE 202
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

5020 E BELTLINE AVE NE STE 202
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-405-0637
  • Fax:
Mailing address:
  • Phone: 616-405-0637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801097901
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: