Individual
GREGORY SHANE DIRICKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPTA
Contact information
Practice address
1105 E FITZGERALD ST, BANGS, TX 76823-3232
(325) 752-7682
Mailing address
2803 14TH ST, BROWNWOOD, TX 76801-7911
(325) 330-2370
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2128687
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22987159
DRIVER'S LICENSE
TX
Enumeration date
05/01/2019
Last updated
05/01/2019
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