Provider Demographics
NPI:1245388917
Name:DICKMAN, NEISHA ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:NEISHA
Middle Name:ANN
Last Name:DICKMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 S KLUG RD
Mailing Address - Street 2:
Mailing Address - City:HARBOR BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:48441-8713
Mailing Address - Country:US
Mailing Address - Phone:989-479-0452
Mailing Address - Fax:989-479-3603
Practice Address - Street 1:305 S KLUG RD
Practice Address - Street 2:
Practice Address - City:HARBOR BEACH
Practice Address - State:MI
Practice Address - Zip Code:48441-8713
Practice Address - Country:US
Practice Address - Phone:989-479-0452
Practice Address - Fax:989-479-3603
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C25703OtherBLUE CROSS PROVIDER
MI0N37880Medicare ID - Type UnspecifiedPHYSICAL THERAPIST