Healthcare Provider Details

I. General information

NPI: 1619416088
Provider Name (Legal Business Name): RYAN MARK DICKERMAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2017
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 VALLEY RD
MOCKSVILLE NC
27028-2930
US

IV. Provider business mailing address

1200 CORPORATE DR STE 400
HOOVER AL
35242-5424
US

V. Phone/Fax

Practice location:
  • Phone: 336-753-3050
  • Fax:
Mailing address:
  • Phone: 423-238-7217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberP16899
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: