Provider Demographics
NPI:1881030096
Name:DICKERSON, DE ANNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:DE
Middle Name:ANNA
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 46TH STREET PL
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-2651
Mailing Address - Country:US
Mailing Address - Phone:309-762-3006
Mailing Address - Fax:
Practice Address - Street 1:1120 46TH STREET PL
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-2651
Practice Address - Country:US
Practice Address - Phone:309-762-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.002979225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist