Basic Information
| Provider Information | |||||||||
| NPI: | 1407858210 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DYKHOUSE | ||||||||
| FirstName: | CONSTANCE | ||||||||
| MiddleName: | LOU | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DYKHOUSE | ||||||||
| OtherFirstName: | CONNIE | ||||||||
| OtherMiddleName: | LOU | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1084 | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934651084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054342748 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 PARK ST | ||||||||
| Address2: | |||||||||
| City: | PASO ROBLES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934462160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8052370272 | ||||||||
| FaxNumber: | 8052372416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT11074 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT11074 | 01 | CA | PT BOARD OF CA | OTHER |