Healthcare Provider Details

I. General information

NPI: 1689982613
Provider Name (Legal Business Name): THERESA M DICKERSON LMT, CBW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 N MERIDIAN ST
INDIANAPOLIS IN
46208-7701
US

IV. Provider business mailing address

2002 KOEHNE ST
INDIANAPOLIS IN
46202-1042
US

V. Phone/Fax

Practice location:
  • Phone: 678-429-3197
  • Fax:
Mailing address:
  • Phone: 678-429-3197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License NumberMT20901976
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License NumberMT20901976
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT20901976
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: