Provider Demographics
NPI:1972859981
Name:DYKSTRA, PAULA RENEE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:PAULA
Middle Name:RENEE
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 CADDIE DR
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5119
Mailing Address - Country:US
Mailing Address - Phone:815-922-9206
Mailing Address - Fax:
Practice Address - Street 1:555 E NORTH ST
Practice Address - Street 2:SUITE D
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1226
Practice Address - Country:US
Practice Address - Phone:815-935-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0137921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical