Healthcare Provider Details

I. General information

NPI: 1811760689
Provider Name (Legal Business Name): RACHEL DYKSTRA MS CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2023
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 OLD SCHOOL FOREST LN
SPARTA MI
49345-9594
US

IV. Provider business mailing address

536 OLD SCHOOL FOREST LN
SPARTA MI
49345-9594
US

V. Phone/Fax

Practice location:
  • Phone: 616-250-6987
  • Fax:
Mailing address:
  • Phone: 616-250-6987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101007354
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: