Provider Demographics
NPI:1063180438
Name:DICKERSON, SEAN
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 412313
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5424
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:
Practice Address - Street 1:189 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3051
Practice Address - Country:US
Practice Address - Phone:828-417-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MDCP034948T225100000X
SC12056225100000X
NCP20741225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist