Provider Demographics
NPI:1659700409
Name:DICKERSON, LIGIA (LOT)
Entity Type:Individual
Prefix:
First Name:LIGIA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 8TH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4137
Mailing Address - Country:US
Mailing Address - Phone:817-921-3000
Mailing Address - Fax:817-921-3001
Practice Address - Street 1:1307 8TH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4137
Practice Address - Country:US
Practice Address - Phone:817-921-3000
Practice Address - Fax:817-921-3001
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist