Provider Demographics
NPI:1639604622
Name:DICKSON, CHRISTINE MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 STONEBURY LOOP RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3936
Mailing Address - Country:US
Mailing Address - Phone:801-631-9796
Mailing Address - Fax:
Practice Address - Street 1:2651 STONEBURY LOOP RD
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-3936
Practice Address - Country:US
Practice Address - Phone:801-631-9796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT75736642402225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant