Provider Demographics
NPI:1578074423
Name:DICKERSON, AMY MARIE (ATR)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 PRAIRIE LN
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-7040
Mailing Address - Country:US
Mailing Address - Phone:612-805-0882
Mailing Address - Fax:
Practice Address - Street 1:1821 UNIVERSITY AVE W STE N385
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-2872
Practice Address - Country:US
Practice Address - Phone:612-326-7579
Practice Address - Fax:612-326-7579
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12-36221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Single Specialty