Provider Demographics
NPI:1699653352
Name:DICKERSON, MAYA (PTA)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 CARLIN AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-6931
Mailing Address - Country:US
Mailing Address - Phone:916-213-7958
Mailing Address - Fax:916-213-7958
Practice Address - Street 1:7281 LONE PINE DR STE D103-A
Practice Address - Street 2:
Practice Address - City:RANCHO MURIETA
Practice Address - State:CA
Practice Address - Zip Code:95683-9715
Practice Address - Country:US
Practice Address - Phone:916-354-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52476225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant