Provider Demographics
NPI:1316253107
Name:DICKERSON, DERRYL S (DC, PTA)
Entity type:Individual
Prefix:
First Name:DERRYL
Middle Name:S
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:DC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 WINDCLIFF DR SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-3801
Mailing Address - Country:US
Mailing Address - Phone:256-225-0495
Mailing Address - Fax:
Practice Address - Street 1:2850 JOHNSON FERRY RD STE 150
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8317
Practice Address - Country:US
Practice Address - Phone:770-518-8786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA002699225200000X
GACHIR010363111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant