Provider Demographics
NPI:1386762938
Name:DICKSON, MARK T
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:T
Last Name:DICKSON
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 1:2400 LEECHBURG RD
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-4673
Mailing Address - Country:US
Mailing Address - Phone:724-337-9933
Mailing Address - Fax:724-337-7677
Practice Address - Street 1:2400 LEECHBURG RD
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-4673
Practice Address - Country:US
Practice Address - Phone:724-337-9933
Practice Address - Fax:724-337-7677
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT000331L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA200084OtherHIGHMARK BC BS
PA2000084Medicare ID - Type Unspecified