Healthcare Provider Details

I. General information

NPI: 1811062953
Provider Name (Legal Business Name): KIM ELIZABETH DYSON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5600 GULF CREEK CIR
THEODORE AL
36582-2586
US

IV. Provider business mailing address

5600 GULF CREEK CIR
THEODORE AL
36582-2586
US

V. Phone/Fax

Practice location:
  • Phone: 251-209-1505
  • Fax: 251-433-5901
Mailing address:
  • Phone: 251-209-1505
  • Fax: 251-433-5901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1811062953
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: