Provider Demographics
NPI:1912246497
Name:DICKERSON, COURTNEY LYN (LMT)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYN
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 SE ASH ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-2504
Mailing Address - Country:US
Mailing Address - Phone:503-871-9548
Mailing Address - Fax:
Practice Address - Street 1:1880 LANCASTER DR NE
Practice Address - Street 2:101, 102
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1089
Practice Address - Country:US
Practice Address - Phone:503-362-1002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18742225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist