=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275153512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN D DICKENS PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2020
-----------------------------------------------------
Last Update Date | 04/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18118 FM 344 W
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75762-6010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-590-5970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10973 COUNTY ROAD 152 W
-----------------------------------------------------
City | BULLARD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75757-8564
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-352-9194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2055797
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------