Provider Demographics
NPI:1013968882
Name:DICKSON, HOLLY KRISTEN (PT)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:KRISTEN
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5624
Mailing Address - Country:US
Mailing Address - Phone:817-707-7025
Mailing Address - Fax:817-491-3807
Practice Address - Street 1:2800 E.STATE HWY 114
Practice Address - Street 2:SUITE 220
Practice Address - City:ROANOKE
Practice Address - State:TX
Practice Address - Zip Code:76262-5624
Practice Address - Country:US
Practice Address - Phone:817-491-3403
Practice Address - Fax:817-491-3308
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1136273225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85811TOtherBCBS
TX456844Medicare ID - Type Unspecified