Provider Demographics
NPI:1821584111
Name:DYKSTRA, MICHELE RAE (MA-CCC, SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:RAE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MA-CCC, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-1376
Mailing Address - Country:US
Mailing Address - Phone:616-866-6859
Mailing Address - Fax:
Practice Address - Street 1:521 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-1376
Practice Address - Country:US
Practice Address - Phone:616-866-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist