Provider Demographics
NPI:1851139059
Name:DICKERSON, KRISTA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-2533
Mailing Address - Country:US
Mailing Address - Phone:304-840-3009
Mailing Address - Fax:
Practice Address - Street 1:2000 ASHLAND DR
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1830
Practice Address - Country:US
Practice Address - Phone:606-480-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-20
Last Update Date:2024-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY287069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist