Provider Demographics
NPI:1831436203
Name:DYKSTRA, ANN-MARIE ALICE (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:ANN-MARIE
Middle Name:ALICE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:258 MAVRICK DR
Mailing Address - Street 2:
Mailing Address - City:MILLS RIVER
Mailing Address - State:NC
Mailing Address - Zip Code:28759
Mailing Address - Country:US
Mailing Address - Phone:352-818-7368
Mailing Address - Fax:
Practice Address - Street 1:1303 LIMIT AVE STE 201
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-3135
Practice Address - Country:US
Practice Address - Phone:352-508-7789
Practice Address - Fax:352-855-0459
Is Sole Proprietor?:No
Enumeration Date:2013-01-05
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14390235Z00000X
FLSA 11970235Z00000X
CO0000452235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist