Provider Demographics
NPI:1558055137
Name:SENSORY SYSTEMS CLINIC WEST
Entity Type:Organization
Organization Name:SENSORY SYSTEMS CLINIC WEST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:616-795-3851
Mailing Address - Street 1:1897 140TH AVE
Mailing Address - Street 2:
Mailing Address - City:DORR
Mailing Address - State:MI
Mailing Address - Zip Code:49323-9119
Mailing Address - Country:US
Mailing Address - Phone:616-795-3851
Mailing Address - Fax:
Practice Address - Street 1:145 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:MI
Practice Address - Zip Code:49348-1701
Practice Address - Country:US
Practice Address - Phone:269-792-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty