Healthcare Provider Details

I. General information

NPI: 1215175567
Provider Name (Legal Business Name): MELISSA GEAN DYKSTRA LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2009
Last Update Date: 01/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 DUNCAN AVE APT 1415
PITTSBURGH PA
15237-5062
US

IV. Provider business mailing address

710 DUNCAN AVE APT 1415 PITTSBURGH
PITTSBURGH PA
15237-5062
US

V. Phone/Fax

Practice location:
  • Phone: 866-482-7485
  • Fax:
Mailing address:
  • Phone: 412-548-3319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW015936
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085405
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: