Provider Demographics
NPI:1053784363
Name:DICKERSON, SYDNEY SHEA
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:SHEA
Last Name:DICKERSON
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 1:10702 E STATE ROAD 156
Mailing Address - Street 2:
Mailing Address - City:VEVAY
Mailing Address - State:IN
Mailing Address - Zip Code:47043-2722
Mailing Address - Country:US
Mailing Address - Phone:812-532-0822
Mailing Address - Fax:
Practice Address - Street 1:10702 E STATE ROAD 156
Practice Address - Street 2:
Practice Address - City:VEVAY
Practice Address - State:IN
Practice Address - Zip Code:47043-2722
Practice Address - Country:US
Practice Address - Phone:812-532-0822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer