Healthcare Provider Details

I. General information

NPI: 1891391314
Provider Name (Legal Business Name): DEBRA LEE DYKHOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 ROCKFORD AVE E
DELANO MN
55328-9186
US

IV. Provider business mailing address

795 ROCKFORD AVE E
DELANO MN
55328-9186
US

V. Phone/Fax

Practice location:
  • Phone: 612-419-7372
  • Fax:
Mailing address:
  • Phone: 612-419-7372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT3400737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: