Provider Demographics
NPI:1437842259
Name:DICKERSON, CARMEN
Entity Type:Individual
Prefix:
First Name:CARMEN
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 1:122 S WAYNE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45215-4579
Mailing Address - Country:US
Mailing Address - Phone:513-526-3004
Mailing Address - Fax:
Practice Address - Street 1:122 S WAYNE AVE STE A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-4579
Practice Address - Country:US
Practice Address - Phone:513-526-3004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRT178541172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty