Basic Information
| Provider Information | |||||||||
| NPI: | 1548684616 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKINSON | ||||||||
| FirstName: | GLORYGRACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3402 CARL STEINER RD | ||||||||
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| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283111646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9105847353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1700 PAMALEE DR | ||||||||
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| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283012824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2014 | ||||||||
| LastUpdateDate: | 02/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A4807 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.