Healthcare Provider Details

I. General information

NPI: 1306240791
Provider Name (Legal Business Name): CAROLE DICKSON CAC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 E 18TH AVE STE C
DENVER CO
80206-1225
US

IV. Provider business mailing address

2222 E 18TH AVE STE C
DENVER CO
80206-1225
US

V. Phone/Fax

Practice location:
  • Phone: 303-062-9529
  • Fax: 303-534-2431
Mailing address:
  • Phone: 303-062-9529
  • Fax: 303-534-2431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACC.0005187
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: