Provider Demographics
NPI:1184141483
Name:DICKSON, KIM SUZANNE
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:SUZANNE
Last Name:DICKSON
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 1:711 PETERSON ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-3318
Mailing Address - Country:US
Mailing Address - Phone:970-482-6114
Mailing Address - Fax:
Practice Address - Street 1:1330 OAKRIDGE DR UNIT 10
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9652
Practice Address - Country:US
Practice Address - Phone:970-419-0486
Practice Address - Fax:970-221-5751
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00000690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist