Healthcare Provider Details

I. General information

NPI: 1215059332
Provider Name (Legal Business Name): EVERETT T DICKERSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 S UNION ST
WILMINGTON DE
19805-3857
US

IV. Provider business mailing address

216 S UNION ST
WILMINGTON DE
19805-3857
US

V. Phone/Fax

Practice location:
  • Phone: 301-391-0508
  • Fax:
Mailing address:
  • Phone: 302-391-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00708500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7934-MH-CC
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC007573
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPC0000911
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: