Provider Demographics
NPI:1477813129
Name:EMILY DYKSTRA MA, CCC-SLP INC.
Entity Type:Organization
Organization Name:EMILY DYKSTRA MA, CCC-SLP INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:407-928-5378
Mailing Address - Street 1:1146 WOODLAND TERRACE TRL
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-1805
Mailing Address - Country:US
Mailing Address - Phone:407-928-5378
Mailing Address - Fax:407-522-8293
Practice Address - Street 1:1146 WOODLAND TERRACE TRL
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-1805
Practice Address - Country:US
Practice Address - Phone:407-928-5378
Practice Address - Fax:407-522-8293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA7153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890146500Medicaid