Basic Information
| Provider Information | |||||||||
| NPI: | 1780745422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYKSTRA | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7086 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | JENISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494289352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166679551 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7086 8TH AVE | ||||||||
| Address2: | |||||||||
| City: | JENISON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494289352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166679551 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6301013027 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | 103TB0200X | 6301013027 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | 6301013027 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | 6301013027 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TM1800X | 6301013027 | MI | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.