Provider Demographics
NPI:1659668135
Name:DYKMAN, ELISSA JEANE (OT)
Entity Type:Individual
Prefix:MRS
First Name:ELISSA
Middle Name:JEANE
Last Name:DYKMAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:ELISSA
Other - Middle Name:JEANE
Other - Last Name:WORTHEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:402 15TH AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3709
Mailing Address - Country:US
Mailing Address - Phone:253-697-5200
Mailing Address - Fax:
Practice Address - Street 1:402 15TH AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3709
Practice Address - Country:US
Practice Address - Phone:253-697-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60217771225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist