Healthcare Provider Details

I. General information

NPI: 1366544553
Provider Name (Legal Business Name): MARC T DICKER PAC, LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 12/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7829 E ROCKHILL ST SUITE 101
WICHITA KS
67206-3920
US

IV. Provider business mailing address

7829 E ROCKHILL ST SUITE 101
WICHITA KS
67206-3920
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-5195
  • Fax: 316-686-8714
Mailing address:
  • Phone: 316-686-5195
  • Fax: 316-686-8714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-15-00156
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-15-00156
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC-127
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: