Healthcare Provider Details

I. General information

NPI: 1184667321
Provider Name (Legal Business Name): SHIRLEY J DZIKOWSKI P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 CANVASBACK RD
MOORESVILLE NC
28117-8134
US

IV. Provider business mailing address

503 CANVASBACK RD
MOORESVILLE NC
28117-8134
US

V. Phone/Fax

Practice location:
  • Phone: 704-677-7905
  • Fax: 704-677-7904
Mailing address:
  • Phone: 704-677-7905
  • Fax: 704-677-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6107
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: