Provider Demographics
NPI:1376108704
Name:DIRICKSON, GREGORY SHANE (LPTA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SHANE
Last Name:DIRICKSON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 14TH ST
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-7911
Mailing Address - Country:US
Mailing Address - Phone:325-330-2370
Mailing Address - Fax:
Practice Address - Street 1:1105 E FITZGERALD ST
Practice Address - Street 2:
Practice Address - City:BANGS
Practice Address - State:TX
Practice Address - Zip Code:76823-3232
Practice Address - Country:US
Practice Address - Phone:325-752-7682
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2128687225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX22987159OtherDRIVER'S LICENSE