Provider Demographics
NPI:1275092173
Name:DYKSTRA, VANESSA (CSW)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46181 272ND ST
Mailing Address - Street 2:
Mailing Address - City:CHANCELLOR
Mailing Address - State:SD
Mailing Address - Zip Code:57015-5320
Mailing Address - Country:US
Mailing Address - Phone:605-413-5614
Mailing Address - Fax:
Practice Address - Street 1:46181 272ND ST
Practice Address - Street 2:
Practice Address - City:CHANCELLOR
Practice Address - State:SD
Practice Address - Zip Code:57015-5320
Practice Address - Country:US
Practice Address - Phone:605-413-5614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD35831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical