Provider Demographics
NPI:1801271747
Name:DICKERSON, ASHLEY LARAE (ATC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LARAE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17607 HIGHWAY 31 S
Mailing Address - Street 2:
Mailing Address - City:HENRYVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47126-8638
Mailing Address - Country:US
Mailing Address - Phone:812-786-7083
Mailing Address - Fax:
Practice Address - Street 1:375 BIRCH ST
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3418
Practice Address - Country:US
Practice Address - Phone:304-293-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer