Provider Demographics
NPI:1487307401
Name:DYKEMAN, ANGELIA (SLP)
Entity type:Individual
Prefix:
First Name:ANGELIA
Middle Name:
Last Name:DYKEMAN
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 1:921 W BEACON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:MS
Mailing Address - Zip Code:39350-3229
Mailing Address - Country:US
Mailing Address - Phone:601-650-0002
Mailing Address - Fax:601-650-9902
Practice Address - Street 1:237 N WOODLAND DR
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-3307
Practice Address - Country:US
Practice Address - Phone:601-564-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-4877235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty