Provider Demographics
NPI:1932411790
Name:DIMSON, KHADEJAR T (MS,CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KHADEJAR
Middle Name:T
Last Name:DIMSON
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:MS
Other - First Name:KHADEJAR
Other - Middle Name:T
Other - Last Name:ADDO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:870 LENOX RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2519
Mailing Address - Country:US
Mailing Address - Phone:917-297-4287
Mailing Address - Fax:
Practice Address - Street 1:512 CARROLL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-1030
Practice Address - Country:US
Practice Address - Phone:718-624-5271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015579-1251C00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251C00000XAgenciesDay Training, Developmentally Disabled Services