Healthcare Provider Details

I. General information

NPI: 1841666880
Provider Name (Legal Business Name): KIMBERLY DYKSTRA SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 NE 139TH ST STE 200
VANCOUVER WA
98686
US

IV. Provider business mailing address

1650 NW NAITO PKWY STE 185
PORTLAND OR
97209-2535
US

V. Phone/Fax

Practice location:
  • Phone: 503-525-7694
  • Fax:
Mailing address:
  • Phone: 503-525-7694
  • Fax: 503-525-7652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60805891
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: