Provider Demographics
NPI:1558372466
Name:DICKENSON, AUGUSTA L (OT)
Entity Type:Individual
Prefix:
First Name:AUGUSTA
Middle Name:L
Last Name:DICKENSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:AUGUSTA
Other - Middle Name:L
Other - Last Name:STEFANICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:PO BOX 922
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-0922
Mailing Address - Country:US
Mailing Address - Phone:866-309-5567
Mailing Address - Fax:812-491-1269
Practice Address - Street 1:5828 PEARL DR
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47712-8116
Practice Address - Country:US
Practice Address - Phone:812-437-1420
Practice Address - Fax:812-437-1425
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004333A225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200829310Medicaid
IN200829310Medicaid
IN200829310Medicaid
INP00748310Medicare UPIN
INP00364408Medicare UPIN
IN216070GMedicare PIN