Provider Demographics
NPI:1841653011
Name:DICKSON, ANDREA (ATC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DICKSON
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 1:4100 GRAF DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-3017
Mailing Address - Country:US
Mailing Address - Phone:502-593-4160
Mailing Address - Fax:
Practice Address - Street 1:4100 GRAF DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-3017
Practice Address - Country:US
Practice Address - Phone:502-593-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT4832255A2300X
IN36001285A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer