Provider Demographics
NPI:1609407345
Name:DYKSTRA, LISA (LMFTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6077
Mailing Address - Country:US
Mailing Address - Phone:541-337-0792
Mailing Address - Fax:
Practice Address - Street 1:450 COUNTRY CLUB RD STE 320
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-5011
Practice Address - Country:US
Practice Address - Phone:541-337-0792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR7770106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist