Provider Demographics
NPI:1750197455
Name:DYKMAN, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:DYKMAN
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 1:314 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-3816
Mailing Address - Country:US
Mailing Address - Phone:360-388-7172
Mailing Address - Fax:
Practice Address - Street 1:601 E PIONEER AVE STE 203
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7694
Practice Address - Country:US
Practice Address - Phone:907-435-1071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2314162355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant