Basic Information
| Provider Information | |||||||||
| NPI: | 1013968882 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | KRISTEN | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 SKYLINE DR | ||||||||
| Address2: | |||||||||
| City: | TROPHY CLUB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762625624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177077025 | ||||||||
| FaxNumber: | 8174913807 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 E.STATE HWY 114 | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | ROANOKE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762625624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174913403 | ||||||||
| FaxNumber: | 8174913308 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 06/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1136273 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 85811T | 01 | TX | BCBS | OTHER |