Provider Demographics
NPI:1639440845
Name:DICKERSON, LIZA MARIANA (MOT)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:MARIANA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3418
Mailing Address - Country:US
Mailing Address - Phone:915-533-3511
Mailing Address - Fax:915-533-3522
Practice Address - Street 1:2009 MONTANA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3418
Practice Address - Country:US
Practice Address - Phone:915-533-3511
Practice Address - Fax:915-533-3522
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist