Healthcare Provider Details

I. General information

NPI: 1306299052
Provider Name (Legal Business Name): KATHLEEN DICKINSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2840 NW 2ND AVE STE 104
BOCA RATON FL
33431-6692
US

IV. Provider business mailing address

6801 HUTCHES RD
BATH NY
14810-7806
US

V. Phone/Fax

Practice location:
  • Phone: 800-233-5976
  • Fax:
Mailing address:
  • Phone: 607-346-6745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1046320161
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: