Healthcare Provider Details

I. General information

NPI: 1982904645
Provider Name (Legal Business Name): WAYNE RICHARD DYKSTRA PHD, M.A., LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2010
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6533 B 35TH AVE. NE
SEATTLE WA
98115-2032
US

IV. Provider business mailing address

6533 B 35TH AVE. NORTH EAST
SEATTLE WA
98115-2032
US

V. Phone/Fax

Practice location:
  • Phone: 206-399-5776
  • Fax:
Mailing address:
  • Phone: 206-399-5776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60165739
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: