Provider Demographics
NPI:1770828600
Name:DICKERHOFF, DONNA
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:DICKERHOFF
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 1:8402 CROSS PARK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78754-4595
Mailing Address - Country:US
Mailing Address - Phone:512-697-8500
Mailing Address - Fax:
Practice Address - Street 1:8402 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78754-4595
Practice Address - Country:US
Practice Address - Phone:512-697-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX825324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility