Provider Demographics
NPI:1689046179
Name:DICKERSON, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BACK FORTY LN
Mailing Address - Street 2:
Mailing Address - City:EVENING SHADE
Mailing Address - State:AR
Mailing Address - Zip Code:72532-9004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 BACK FORTY LN
Practice Address - Street 2:
Practice Address - City:EVENING SHADE
Practice Address - State:AR
Practice Address - Zip Code:72532-9004
Practice Address - Country:US
Practice Address - Phone:870-266-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3969225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant