Provider Demographics
NPI:1407858210
Name:DYKHOUSE, CONSTANCE LOU (PT)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:LOU
Last Name:DYKHOUSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:CONNIE
Other - Middle Name:LOU
Other - Last Name:DYKHOUSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 1084
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-1084
Mailing Address - Country:US
Mailing Address - Phone:805-434-2748
Mailing Address - Fax:805-237-2416
Practice Address - Street 1:1414 PARK ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2160
Practice Address - Country:US
Practice Address - Phone:805-237-0272
Practice Address - Fax:805-237-2416
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT11074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT11074OtherPT BOARD OF CA
W15109Medicare ID - Type Unspecified