Provider Demographics
NPI:1093032450
Name:DICKERSON, SUSAN MARIE PAUL (OTR/L)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE PAUL
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 PRIMACY PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-0000
Mailing Address - Country:US
Mailing Address - Phone:901-767-1040
Mailing Address - Fax:901-374-9603
Practice Address - Street 1:6025 PRIMACY PARKWAY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5763
Practice Address - Country:US
Practice Address - Phone:901-767-1040
Practice Address - Fax:901-374-9603
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2010-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist