Individual
SHANTIL DICKERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
22 NW 11TH ST., RICHMOND, IN 47374
(330) 716-2285
Mailing address
1100 REID PARKWAY, MEDICAL STAFF SERVICES, RICHMOND, IN 47374-1157
(937) 456-4181
(937) 456-4649
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
05012095A
IN
225100000X
Physical Therapist
Primary
PT016442
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PENDING
ANTHEM
—
05
—
PENDING
—
IN
05
—
PENDING
—
OH
Enumeration date
02/06/2017
Last updated
08/01/2018
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