Healthcare Provider Details

I. General information

NPI: 1508402348
Provider Name (Legal Business Name): MARSHA DYKSTRA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

IV. Provider business mailing address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-3909
  • Fax: 616-336-8830
Mailing address:
  • Phone: 616-336-3909
  • Fax: 616-336-8830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401017932
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: