Healthcare Provider Details

I. General information

NPI: 1376205161
Provider Name (Legal Business Name): DANIELLE L DICKINSON MSSA, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DYLAN DICKINSON

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 BRIDGE AVE
CLEVELAND OH
44113-3304
US

IV. Provider business mailing address

4115 BRIDGE AVE
CLEVELAND OH
44113-3304
US

V. Phone/Fax

Practice location:
  • Phone: 216-631-5800
  • Fax:
Mailing address:
  • Phone: 216-631-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2107010
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: