Healthcare Provider Details

I. General information

NPI: 1265632244
Provider Name (Legal Business Name): BRUCE DYKEMAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 POINT FOSDICK DR NW SUITE 200
GIG HARBOR WA
98335-1797
US

IV. Provider business mailing address

PO BOX 1487
GIG HARBOR WA
98335-3487
US

V. Phone/Fax

Practice location:
  • Phone: 262-909-0105
  • Fax:
Mailing address:
  • Phone: 262-909-0105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00002833
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1485
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number71-002164
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: