Healthcare Provider Details

I. General information

NPI: 1255650800
Provider Name (Legal Business Name): MERCEDES DICKINSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2010
Last Update Date: 11/05/2023
Certification Date: 11/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1744 E MCANDREWS RD STE J
MEDFORD OR
97504-5576
US

IV. Provider business mailing address

308 WINDSOR AVE
MEDFORD OR
97504-8052
US

V. Phone/Fax

Practice location:
  • Phone: 832-729-7687
  • Fax:
Mailing address:
  • Phone: 832-729-7687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2052
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number2052
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: