Provider Demographics
NPI:1164297073
Name:DICKSON, TINA MICHELLE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:MICHELLE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 103RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE STEVENS
Mailing Address - State:WA
Mailing Address - Zip Code:98258-7921
Mailing Address - Country:US
Mailing Address - Phone:425-268-1572
Mailing Address - Fax:
Practice Address - Street 1:9327 4TH ST NE STE 5
Practice Address - Street 2:
Practice Address - City:LAKE STEVENS
Practice Address - State:WA
Practice Address - Zip Code:98258-1630
Practice Address - Country:US
Practice Address - Phone:425-512-9212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61347352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist