Healthcare Provider Details

I. General information

NPI: 1184553786
Provider Name (Legal Business Name): DANIELLE DICKERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 W REDONDO BEACH BLVD UNIT 2681
GARDENA CA
90247-6541
US

IV. Provider business mailing address

1455 W REDONDO BEACH BLVD UNIT 2681
GARDENA CA
90247-6541
US

V. Phone/Fax

Practice location:
  • Phone: 310-749-9483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number163461
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: