Provider Demographics
NPI:1124426473
Name:DYKEMAN, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:DYKEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:772 SLEEPY HOLLOW RD
Mailing Address - Street 2:#1155
Mailing Address - City:ATHENS
Mailing Address - State:NY
Mailing Address - Zip Code:12015-3128
Mailing Address - Country:US
Mailing Address - Phone:518-943-0574
Mailing Address - Fax:518-943-5396
Practice Address - Street 1:770 EMBOUGHT RD
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-5312
Practice Address - Country:US
Practice Address - Phone:518-943-0574
Practice Address - Fax:518-943-5396
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720573771041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool