Provider Demographics
NPI:1972961308
Name:DYKSTRA, SANDRA (MSSW)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2342 N 61ST ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8018 W CAPITOL DR UNIT 6
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1906
Practice Address - Country:US
Practice Address - Phone:414-559-8864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-30
Last Update Date:2016-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI126837-121104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker