Healthcare Provider Details

I. General information

NPI: 1013968882
Provider Name (Legal Business Name): HOLLY KRISTEN DICKSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E.STATE HWY 114 SUITE 220
ROANOKE TX
76262-5624
US

IV. Provider business mailing address

311 SKYLINE DR
TROPHY CLUB TX
76262-5624
US

V. Phone/Fax

Practice location:
  • Phone: 817-491-3403
  • Fax: 817-491-3308
Mailing address:
  • Phone: 817-707-7025
  • Fax: 817-491-3807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1136273
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: