Provider Demographics
NPI:1154555688
Name:DICKINSON, KELLIE DARE (LOT)
Entity type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:DARE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 HYDE PL
Mailing Address - Street 2:
Mailing Address - City:RIVER RIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70123-1521
Mailing Address - Country:US
Mailing Address - Phone:504-831-0449
Mailing Address - Fax:
Practice Address - Street 1:10001 HYDE PL
Practice Address - Street 2:
Practice Address - City:RIVER RIDGE
Practice Address - State:LA
Practice Address - Zip Code:70123-1521
Practice Address - Country:US
Practice Address - Phone:504-831-0449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAZ10176225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAZ10176OtherSTATE BOARD OF MEDICAL EXAMINERS