Healthcare Provider Details

I. General information

NPI: 1134791080
Provider Name (Legal Business Name): STEPHEN E DICKERSON MS, LCAS, LCMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 BUNDABERG LN
RURAL HALL NC
27045-9752
US

IV. Provider business mailing address

780 BUNDABERG LN
RURAL HALL NC
27045-9752
US

V. Phone/Fax

Practice location:
  • Phone: 336-995-3243
  • Fax:
Mailing address:
  • Phone: 336-995-3243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberA17103
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-27181
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: