Provider Demographics
NPI:1962846014
Name:DYKSTRA, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:HOLMQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16081 64TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-7712
Mailing Address - Country:US
Mailing Address - Phone:269-910-6889
Mailing Address - Fax:
Practice Address - Street 1:16081 64TH ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-7712
Practice Address - Country:US
Practice Address - Phone:269-910-6889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007810101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional