Basic Information
| Provider Information | |||||||||
| NPI: | 1245850551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | MACY | ||||||||
| MiddleName: | UNDERWOOD | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3962 JOHNSTOWN DR | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361092310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3346693964 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 304 TURNER MCCALL BLVD SW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301655621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065095000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2020 | ||||||||
| LastUpdateDate: | 04/16/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4271 | AL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SLP010928 | GA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.