Healthcare Provider Details

I. General information

NPI: 1659806990
Provider Name (Legal Business Name): GLORIA DYKSTRA L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2017
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 E MADISON ST SUITE 204
SEATTLE WA
98112-4749
US

IV. Provider business mailing address

6533B 35TH AVE NE
SEATTLE WA
98115-7331
US

V. Phone/Fax

Practice location:
  • Phone: 206-399-5422
  • Fax:
Mailing address:
  • Phone: 206-399-5422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60735584
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: