Provider Demographics
NPI:1437464674
Name:DICKERSON, KYLEEN K (OT)
Entity Type:Individual
Prefix:
First Name:KYLEEN
Middle Name:K
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:KYLEEN
Other - Middle Name:C
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:10010 FALLS OF NEUSE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8494
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-350-1508
Practice Address - Fax:919-350-1475
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011525225X00000X
VA0119005582225X00000X
NC8043225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist