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General NPI Number Information
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NPI Number | 1972961308
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Entity Type | Individual
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Provider Name | SANDRA DYKSTRA MSSW
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Gender | Female
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Dates
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Enumeration Date | 01/30/2016
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Last Update Date | 01/30/2016
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Provider Practice Location Address
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Address Line | 8018 W CAPITOL DR UNIT 6
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City | MILWAUKEE
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State | WI
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Zip | 53222-1906
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Country | US
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Telephone | 414-559-8864
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Fax |
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Provider Business Mailing Address
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Address Line | 2342 N 61ST ST
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City | WAUWATOSA
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State | WI
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Zip | 53213-1504
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 126837-121
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License Number State | WI
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