Provider Demographics
NPI:1730804535
Name:DYKSTRA, AMANDA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:DYKSTRA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9209 W WAKEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-6708
Mailing Address - Country:US
Mailing Address - Phone:714-501-0557
Mailing Address - Fax:
Practice Address - Street 1:9209 W WAKEFIELD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-6708
Practice Address - Country:US
Practice Address - Phone:714-501-0557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID5014235Z00000X
ND2025235Z00000X
CA00003878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist