Provider Demographics
NPI:1134222433
Name:DICKERSON, ERIC DALE (MS CCC/SLP)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DALE
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 RAMEY RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351
Mailing Address - Country:US
Mailing Address - Phone:606-356-3848
Mailing Address - Fax:
Practice Address - Street 1:933 N TOLLIVER RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1347
Practice Address - Country:US
Practice Address - Phone:606-356-3848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-2795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist