Provider Demographics
NPI:1679079354
Name:DICKSON, AMY (PT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:CLEGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:540 BUCKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3618
Mailing Address - Country:US
Mailing Address - Phone:215-357-3068
Mailing Address - Fax:
Practice Address - Street 1:540 BUCKSTONE DR
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3618
Practice Address - Country:US
Practice Address - Phone:215-357-3068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA013841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist