Provider Demographics
NPI:1962653014
Name:DICKERSON, TAYLOR LAYNE (PT)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:LAYNE
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 SILVER SAGE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4179
Mailing Address - Country:US
Mailing Address - Phone:918-814-5877
Mailing Address - Fax:
Practice Address - Street 1:1181 MALL DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8105
Practice Address - Country:US
Practice Address - Phone:575-522-0766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3586225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist