Provider Demographics
NPI:1568178390
Name:DICKINSON, AVERY JUSTINE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:JUSTINE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-4626
Mailing Address - Country:US
Mailing Address - Phone:712-396-6025
Mailing Address - Fax:712-936-6286
Practice Address - Street 1:933 E PIERCE ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4626
Practice Address - Country:US
Practice Address - Phone:712-396-6025
Practice Address - Fax:712-396-6286
Is Sole Proprietor?:No
Enumeration Date:2023-01-25
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096870225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist