Provider Demographics
NPI:1477016327
Name:DICKERSON, BENJAMIN LANE (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:LANE
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W 6TH AVE APT 13
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-2469
Mailing Address - Country:US
Mailing Address - Phone:419-618-5565
Mailing Address - Fax:
Practice Address - Street 1:3207 HILLIARD ROME RD
Practice Address - Street 2:
Practice Address - City:HILLIARD
Practice Address - State:OH
Practice Address - Zip Code:43026
Practice Address - Country:US
Practice Address - Phone:614-850-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84032251S0007X
SCBOC1543022255A2300X
OHPT.0150692251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer