Provider Demographics
NPI:1154844025
Name:DICKERSON, HEATHER (MED)
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W EVERGREEN AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-7113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 W EVERGREEN AVE STE 404
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-7113
Practice Address - Country:US
Practice Address - Phone:312-242-1665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist