Provider Demographics
NPI:1285432740
Name:DICKERSON, BRYANT
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44306-2020
Mailing Address - Country:US
Mailing Address - Phone:440-850-5859
Mailing Address - Fax:440-850-5859
Practice Address - Street 1:400 E STATE ST STE D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1870
Practice Address - Country:US
Practice Address - Phone:740-326-6110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty