Individual
THERESA M DICKERSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LMT, CBW
Contact information
Practice address
2625 N MERIDIAN ST, INDIANAPOLIS, IN 46208-7701
(678) 429-3197
Mailing address
2002 KOEHNE ST, INDIANAPOLIS, IN 46202-1042
(678) 429-3197
Taxonomy
Speciality
Code
Description
License number
State
173C00000X
Reflexologist
MT20901976
IN
225500000X
Respiratory/Developmental/Rehabilitative Specialist/Technologist
MT20901976
IN
225700000X
Massage Therapist
Primary
MT20901976
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
MT20901976
STATE LICENSE
IN
Enumeration date
09/24/2010
Last updated
09/24/2010
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