Provider Demographics
NPI:1083172233
Name:DYKSTRA, MARILIZ JIMENEZ (DPT)
Entity Type:Individual
Prefix:
First Name:MARILIZ
Middle Name:JIMENEZ
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7573 W 121ST AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8716
Mailing Address - Country:US
Mailing Address - Phone:219-895-4103
Mailing Address - Fax:
Practice Address - Street 1:7573 W 121ST AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8716
Practice Address - Country:US
Practice Address - Phone:219-895-4103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05011241A2251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics