Provider Demographics
NPI:1467528653
Name:DYKSTRA, KELLY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3310 E CANARY WAY
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-5682
Mailing Address - Country:US
Mailing Address - Phone:480-813-1897
Mailing Address - Fax:480-361-9838
Practice Address - Street 1:3310 E CANARY WAY
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286
Practice Address - Country:US
Practice Address - Phone:480-813-1897
Practice Address - Fax:480-361-9838
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist