Provider Demographics
NPI:1881075679
Name:DICKERSON, COLE EVANS (DPT)
Entity type:Individual
Prefix:
First Name:COLE
Middle Name:EVANS
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 COMMERCE DR STE A
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-1495
Mailing Address - Country:US
Mailing Address - Phone:870-248-0800
Mailing Address - Fax:870-248-0802
Practice Address - Street 1:1415 COMMERCE DR STE A
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-1495
Practice Address - Country:US
Practice Address - Phone:870-248-0800
Practice Address - Fax:870-248-0802
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT0000010465225100000X
AR5351225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0446657Medicaid
TN4004523OtherBCBST
TN0446657Medicaid