Provider Demographics
NPI:1326220054
Name:DICKERSON, NIKKI R (MA)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:R
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5979 BROOKSIDE OAK CIR
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-1753
Mailing Address - Country:US
Mailing Address - Phone:678-451-8789
Mailing Address - Fax:
Practice Address - Street 1:5979 BROOKSIDE OAK CIR
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-1753
Practice Address - Country:US
Practice Address - Phone:678-451-8789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006785235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist