Provider Demographics
NPI:1275602930
Name:DICKINSON, TERRI A (PT)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:A
Last Name:DICKINSON
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 1:3050 UNION CHURCH RD SW
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5430
Mailing Address - Country:US
Mailing Address - Phone:770-378-0855
Mailing Address - Fax:770-860-0120
Practice Address - Street 1:3050 UNION CHURCH RD SW
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5430
Practice Address - Country:US
Practice Address - Phone:770-378-0855
Practice Address - Fax:770-860-0120
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0061782251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10046652OtherAMERIGROUP