Provider Demographics
NPI:1245428101
Name:DICKERSON, TAIWAN (MHPP)
Entity Type:Individual
Prefix:
First Name:TAIWAN
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W DAISY BATES DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-5402
Mailing Address - Country:US
Mailing Address - Phone:501-371-9058
Mailing Address - Fax:501-371-9052
Practice Address - Street 1:1020 W DAISY BATES DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72202-5402
Practice Address - Country:US
Practice Address - Phone:501-371-9058
Practice Address - Fax:501-371-9082
Is Sole Proprietor?:No
Enumeration Date:2007-10-04
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator