Provider Demographics
NPI:1689982613
Name:DICKERSON, THERESA M (LMT, CBW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LMT, CBW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 KOEHNE ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1042
Mailing Address - Country:US
Mailing Address - Phone:678-429-3197
Mailing Address - Fax:
Practice Address - Street 1:2625 N MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-7701
Practice Address - Country:US
Practice Address - Phone:678-429-3197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901976173C00000X, 225500000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INMT20901976OtherSTATE LICENSE