Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | 05011241A | IN |
NPI | 1083172233 |
---|---|
Provider Name | Mariliz Jimenez Dykstra |
First Address | Crown Point, IN 46307-8716 |
Second Address | Crown Point, IN 46307-8716 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/03/2019 |
Last Update Date | 06/03/2019 |