Provider Demographics
NPI:1669612552
Name:DICKSON, MICHELE MARISSA (MSCCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:MARISSA
Last Name:DICKSON
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RYAN CT
Mailing Address - Street 2:
Mailing Address - City:PARLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08859-1760
Mailing Address - Country:US
Mailing Address - Phone:917-613-3527
Mailing Address - Fax:
Practice Address - Street 1:3 RYAN CT
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1760
Practice Address - Country:US
Practice Address - Phone:917-613-3527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012809-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist