Provider Demographics
NPI:1922249390
Name:DICKSON, SHIRLEY ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:ANN
Last Name:DICKSON
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 1:4 MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03908-2149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:207-384-5845
Practice Address - Street 1:4 MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTH BERWICK
Practice Address - State:ME
Practice Address - Zip Code:03908-2149
Practice Address - Country:US
Practice Address - Phone:207-216-3410
Practice Address - Fax:207-384-5845
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOT637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0470761OtherCIGNA
ME172880000Medicaid