Healthcare Provider Details

I. General information

NPI: 1659668135
Provider Name (Legal Business Name): ELISSA JEANE DYKMAN O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISSA JEANE WORTHEN O.T.

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 15TH AVE SE STE 100
PUYALLUP WA
98372-3709
US

IV. Provider business mailing address

402 15TH AVE SE STE 100
PUYALLUP WA
98372-3709
US

V. Phone/Fax

Practice location:
  • Phone: 253-697-5200
  • Fax:
Mailing address:
  • Phone: 253-697-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT60217771
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: