Healthcare Provider Details

I. General information

NPI: 1154993749
Provider Name (Legal Business Name): TRELLA DICKMAN MS, LAT, ATC, CSCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15845 TAMARACK LN
SAINT ROBERT MO
65584-9457
US

IV. Provider business mailing address

15845 TAMARACK LN
SAINT ROBERT MO
65584-9457
US

V. Phone/Fax

Practice location:
  • Phone: 620-214-3693
  • Fax:
Mailing address:
  • Phone: 620-214-3693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2023049012
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number24-01711
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: