Healthcare Provider Details

I. General information

NPI: 1841318755
Provider Name (Legal Business Name): JOYCE MARIE DYKSTRA LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 W WOOD ST
NEWAYGO MI
49337
US

IV. Provider business mailing address

221 E OAK ST
FREMONT MI
49412-1649
US

V. Phone/Fax

Practice location:
  • Phone: 231-652-1780
  • Fax: 231-652-1786
Mailing address:
  • Phone: 231-924-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301010718
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: