Provider Demographics
NPI:1184758336
Name:DICKERSON, MARY S S (OT)
Entity type:Individual
Prefix:
First Name:MARY S
Middle Name:S
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 HIGHWAY 34 E STE 140
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2121
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:770-251-8567
Practice Address - Street 1:1755 HIGHWAY 34 E
Practice Address - Street 2:SUITE 1300
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-5631
Practice Address - Country:US
Practice Address - Phone:770-254-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist