Healthcare Provider Details

I. General information

NPI: 1528386372
Provider Name (Legal Business Name): KELLY SUE DICKINSON LICSW, LSCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 MAIN ST SUITE 100
ATCHISON KS
66002-2838
US

IV. Provider business mailing address

201 MAIN ST SUITE 100
ATCHISON KS
66002-2838
US

V. Phone/Fax

Practice location:
  • Phone: 913-367-1593
  • Fax: 913-367-1627
Mailing address:
  • Phone: 913-367-1593
  • Fax: 913-367-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15156
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number4279
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier15156
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerLICENSE NUMBER
# 2
Identifier4279
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerLICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: