Healthcare Provider Details

I. General information

NPI: 1225358385
Provider Name (Legal Business Name): SARA MICHELLE DICKERSON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2010
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WARRINGTON AVE
DANVILLE IL
61832-5446
US

IV. Provider business mailing address

550 FRONTAGE RD SUITE 2415
NORTHFIELD IL
60093-1202
US

V. Phone/Fax

Practice location:
  • Phone: 217-446-0660
  • Fax: 217-446-9839
Mailing address:
  • Phone: 847-441-5593
  • Fax: 847-441-0734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number016.0004032
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: