Provider Demographics
NPI:1992031207
Name:DICKENS, SAMANTHA (CSFA)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:DICKENS
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70458 SILAS THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:LA
Mailing Address - Zip Code:70452-2460
Mailing Address - Country:US
Mailing Address - Phone:985-707-3017
Mailing Address - Fax:
Practice Address - Street 1:70458 SILAS THOMAS RD
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:LA
Practice Address - Zip Code:70452-2460
Practice Address - Country:US
Practice Address - Phone:985-707-3017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2011-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA114115246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant