Provider Demographics
NPI:1023742707
Name:DICKERSON, MYTOSHA MONIQUE (CBS)
Entity type:Individual
Prefix:MRS
First Name:MYTOSHA
Middle Name:MONIQUE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:CBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9082 WINDING LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-0367
Mailing Address - Country:US
Mailing Address - Phone:504-875-6174
Mailing Address - Fax:
Practice Address - Street 1:9082 WINDING LAKE AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-0367
Practice Address - Country:US
Practice Address - Phone:504-875-6174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-10
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care