Provider Demographics
NPI:1841666880
Name:DYKSTRA, KIMBERLY (SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 NW NAITO PKWY STE 185
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2535
Mailing Address - Country:US
Mailing Address - Phone:503-525-7694
Mailing Address - Fax:503-525-7652
Practice Address - Street 1:2121 NE 139TH ST STE 200
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686
Practice Address - Country:US
Practice Address - Phone:503-525-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-13
Last Update Date:2018-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60805891235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist