Healthcare Provider Details

I. General information

NPI: 1366516759
Provider Name (Legal Business Name): DAWN W. DICKERSON LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 MOON ST NE SUITE 3
ALBUQUERQUE NM
87112-2850
US

IV. Provider business mailing address

PO BOX 50369
ALBUQUERQUE NM
87181-0369
US

V. Phone/Fax

Practice location:
  • Phone: 505-450-6175
  • Fax: 505-292-6336
Mailing address:
  • Phone: 505-450-6175
  • Fax: 505-292-6336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0065612
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: