Provider Demographics
NPI:1922122647
Name:DIKES, KORINNE B
Entity Type:Individual
Prefix:
First Name:KORINNE
Middle Name:B
Last Name:DIKES
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 1:9957 DELAMERE DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-8507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:508 S ADAMS ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2147
Practice Address - Country:US
Practice Address - Phone:817-878-2834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109039225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist