Basic Information
| Provider Information | |||||||||
| NPI: | 1649577701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | ALICE MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | OTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10000 W. 75TH ST. | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
| FaxNumber: | 9138941174 | ||||||||
| Practice Location | |||||||||
| Address1: | 10000 W. 75TH ST. | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MERRIAM | ||||||||
| State: | KS | ||||||||
| PostalCode: | 66204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
| FaxNumber: | 9138941174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2011 | ||||||||
| LastUpdateDate: | 02/24/2011 | ||||||||
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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 | 224Z00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225200000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 225X00000X | 2009000971 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 17-022551 | KS | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.