Provider Demographics
NPI:1922574292
Name:DICKERSON, DEIDRA DOUGLAS
Entity Type:Individual
Prefix:
First Name:DEIDRA
Middle Name:DOUGLAS
Last Name:DICKERSON
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 1:1115 TAMARACK RD STE 400
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6934
Mailing Address - Country:US
Mailing Address - Phone:270-926-8534
Mailing Address - Fax:270-685-2058
Practice Address - Street 1:1115 TAMARACK RD STE 400
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6934
Practice Address - Country:US
Practice Address - Phone:270-926-8534
Practice Address - Fax:270-685-2058
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY245161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist