Healthcare Provider Details

I. General information

NPI: 1962846014
Provider Name (Legal Business Name): WENDY DYKSTRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY HOLMQUIST

II. Dates (important events)

Enumeration Date: 04/19/2013
Last Update Date: 11/11/2020
Certification Date: 11/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16081 64TH ST
SOUTH HAVEN MI
49090-7712
US

IV. Provider business mailing address

16081 64TH ST
SOUTH HAVEN MI
49090-7712
US

V. Phone/Fax

Practice location:
  • Phone: 269-910-6889
  • Fax:
Mailing address:
  • Phone: 269-910-6889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401007810
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: