MEDICARE: EBONYE JUNAE DICKENS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor	IMH14452	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114456175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONYE JUNAE DICKENS LMHC

Provider Business Mailing Address
First Line	:	1333 COLLEGE PKWY UNIT 675
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32563-2711
Country	:	US
Telephone Number	:	850-966-3030
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 MIRACLE STRIP PKWY SE STE 121
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5819
Country	:	US
Telephone Number	:	850-966-3030
Fax Number	:	850-563-9100

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2017
Last Update Date	:	10/15/2024

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