Healthcare Provider Details

I. General information

NPI: 1831534213
Provider Name (Legal Business Name): DICKERSON ENTERPRISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

872 VERNON ST
MANCHESTER CT
06042-2415
US

IV. Provider business mailing address

872 VERNON ST
MANCHESTER CT
06042-2415
US

V. Phone/Fax

Practice location:
  • Phone: 860-416-3500
  • Fax:
Mailing address:
  • Phone: 860-416-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3221
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH LEE DICKERSON JR.
Title or Position: CEO
Credential: LPC
Phone: 860-416-3500