Provider Demographics
NPI:1255454591
Name:DICKERSON, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 FOX PL
Mailing Address - Street 2:
Mailing Address - City:S PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-1534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 PARSONAGE RD STE 508
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-2475
Practice Address - Country:US
Practice Address - Phone:732-906-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QB00161000OtherLICENSE#