MEDICARE: QULOTTA LATIFAH DICKERSON

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1922988740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QULOTTA LATIFAH DICKERSON

Provider Business Mailing Address
First Line	:	2001 STOKES AVE APT 704
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-4679
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 STOKES AVE APT 704
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-4679
Country	:	US
Telephone Number	:	803-862-8648
Fax Number	:

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

Provider Enumeration Date	:	09/03/2025
Last Update Date	:	10/24/2025

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