Provider Demographics
NPI:1033936661
Name:DYKSTRA, EMILY
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1256 E ZINNIA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-9573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:441 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:IN
Practice Address - Zip Code:47446-1020
Practice Address - Country:US
Practice Address - Phone:812-849-4481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1587573103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool