Provider Demographics
NPI:1366928632
Name:DYKEHOUSE, PAMELA KAY
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:KAY
Last Name:DYKEHOUSE
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 1:4471 CHANDY DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1311
Mailing Address - Country:US
Mailing Address - Phone:616-676-8835
Mailing Address - Fax:616-575-5123
Practice Address - Street 1:4450 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3633
Practice Address - Country:US
Practice Address - Phone:616-949-5140
Practice Address - Fax:616-575-5123
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003027225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist