Healthcare Provider Details

I. General information

NPI: 1689046179
Provider Name (Legal Business Name): KASEY DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 BACK FORTY LN
EVENING SHADE AR
72532-9004
US

IV. Provider business mailing address

31 BACK FORTY LN
EVENING SHADE AR
72532-9004
US

V. Phone/Fax

Practice location:
  • Phone: 870-266-3323
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number3969
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: