Basic Information
| Provider Information | |||||||||
| NPI: | 1578074423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ATR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 506 PRAIRIE LN | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540167040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128050882 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1821 UNIVERSITY AVE W STE N385 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551042872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123267579 | ||||||||
| FaxNumber: | 6123267579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 221700000X | 12-36 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Art Therapist |
No ID Information.