Provider Demographics
NPI:1326203076
Name:DICKERSON, NADIYAH
Entity Type:Individual
Prefix:
First Name:NADIYAH
Middle Name:
Last Name:DICKERSON
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 1:1595 S CALUMET RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-2389
Mailing Address - Country:US
Mailing Address - Phone:219-764-4888
Mailing Address - Fax:219-898-4258
Practice Address - Street 1:1595 S CALUMET RD STE 3
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-2389
Practice Address - Country:US
Practice Address - Phone:219-764-4888
Practice Address - Fax:219-898-4258
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
IL242000410235Z00000X
IN22006354A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196020AMedicaid