Basic Information
| Provider Information | |||||||||
| NPI: | 1063948198 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | BRITTANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 DEPOSIT DR NE STE 120 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495461467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | 6168053631 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 84TH ST SW STE 102 | ||||||||
| Address2: | |||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493159350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
| FaxNumber: | 6168053631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2017 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401013699 | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 6401013699 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.