Provider Demographics
NPI:1922708619
Name:DICKERSON, DOMINIQUE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5960 ALLISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-5202
Mailing Address - Country:US
Mailing Address - Phone:812-677-8891
Mailing Address - Fax:
Practice Address - Street 1:9957 ALLISONVILLE RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2006
Practice Address - Country:US
Practice Address - Phone:317-841-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22008321A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist