Healthcare Provider Details

I. General information

NPI: 1689112039
Provider Name (Legal Business Name): SHANTIL DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 NW 11TH ST.
RICHMOND IN
47374
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374-1157
US

V. Phone/Fax

Practice location:
  • Phone: 330-716-2285
  • Fax:
Mailing address:
  • Phone: 937-456-4181
  • Fax: 937-456-4649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05012095A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT016442
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: