Healthcare Provider Details

I. General information

NPI: 1952701567
Provider Name (Legal Business Name): MARIA LOUISE DYKSTRA LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 WASHINGTON AVE STE 210
HOLLAND MI
49423-7725
US

IV. Provider business mailing address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

V. Phone/Fax

Practice location:
  • Phone: 616-820-3780
  • Fax: 616-820-3785
Mailing address:
  • Phone: 616-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC.0014471
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401016915
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016915
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: