Provider Demographics
NPI:1134580962
Name:DICKMAN, BRITT
Entity type:Individual
Prefix:
First Name:BRITT
Middle Name:
Last Name:DICKMAN
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 1:855 W CLARK ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4160
Mailing Address - Country:US
Mailing Address - Phone:406-491-1179
Mailing Address - Fax:
Practice Address - Street 1:13279 N MOONGLOW LN
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-5122
Practice Address - Country:US
Practice Address - Phone:208-241-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-07
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-5562255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer