Provider Demographics
NPI:1407736580
Name:DICKS, KAELYN D
Entity type:Individual
Prefix:
First Name:KAELYN
Middle Name:D
Last Name:DICKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 WILLOUGHBY AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-2777
Mailing Address - Country:US
Mailing Address - Phone:770-342-8992
Mailing Address - Fax:
Practice Address - Street 1:1727 AMSTERDAM AVE FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031-4611
Practice Address - Country:US
Practice Address - Phone:770-342-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist