Provider Demographics
NPI:1114394095
Name:DICKERSON, MELINDA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 PEG LN
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-1210
Mailing Address - Country:US
Mailing Address - Phone:662-315-0084
Mailing Address - Fax:479-709-7717
Practice Address - Street 1:404 PEG LN
Practice Address - Street 2:
Practice Address - City:AMORY
Practice Address - State:MS
Practice Address - Zip Code:38821-1210
Practice Address - Country:US
Practice Address - Phone:662-315-0084
Practice Address - Fax:479-709-7717
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT973225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist