Healthcare Provider Details

I. General information

NPI: 1689878936
Provider Name (Legal Business Name): DENISE MICHELLE DICKERSON MS, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SOLOMONS ISLAND RD, N
PRINCE FREDERICK MD
20678-0980
US

IV. Provider business mailing address

PO BOX 980
PRINCE FREDERICK MD
20678-0980
US

V. Phone/Fax

Practice location:
  • Phone: 410-535-5400
  • Fax: 410-535-0736
Mailing address:
  • Phone: 410-535-5400
  • Fax: 410-535-0736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCA2092
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: