Provider Demographics
NPI:1255967642
Name:DICKERSON, STACY BETTS (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:BETTS
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OLYMPIC PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1950
Mailing Address - Country:US
Mailing Address - Phone:903-520-5335
Mailing Address - Fax:903-596-3122
Practice Address - Street 1:701 OLYMPIC PLAZA CIR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1950
Practice Address - Country:US
Practice Address - Phone:903-596-3136
Practice Address - Fax:903-596-3122
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102145235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist