Provider Demographics
NPI:1245360569
Name:DICKSON, CARLA ANN
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:ANN
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 1:101 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-1222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-1222
Practice Address - Country:US
Practice Address - Phone:740-260-1281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2676733251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health