Provider Demographics
NPI:1215214937
Name:DICKSON, TANYA MARY (DPT)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:MARY
Last Name:DICKSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:2618 N SALISBURY BLVD STE 130
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801-2217
Practice Address - Country:US
Practice Address - Phone:410-324-7409
Practice Address - Fax:410-844-4588
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23872225100000X
DEJ1-0003173225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist