Provider Demographics
NPI:1881171619
Name:DICKSON, SANDRA L
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:DICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 SWARTHMORE AVE
Mailing Address - Street 2:ST 204
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4565
Mailing Address - Country:US
Mailing Address - Phone:732-961-6398
Mailing Address - Fax:732-961-6399
Practice Address - Street 1:1935 SWARTHMORE AVE
Practice Address - Street 2:ST 204
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-4565
Practice Address - Country:US
Practice Address - Phone:732-961-6398
Practice Address - Fax:732-961-6399
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1541071343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)