Healthcare Provider Details

I. General information

NPI: 1144134909
Provider Name (Legal Business Name): ELISEBETH MARIE DICKSON MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N UNIVERSITY DR
EDMOND OK
73034-5207
US

IV. Provider business mailing address

100 N UNIVERSITY DR
EDMOND OK
73034-5207
US

V. Phone/Fax

Practice location:
  • Phone: 605-931-3191
  • Fax:
Mailing address:
  • Phone: 605-931-3191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number115014
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: