Healthcare Provider Details

I. General information

NPI: 1114025467
Provider Name (Legal Business Name): LARRY SCOTT DICKSON MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18201 CONNEAUT LAKE RD
MEADVILLE PA
16335-3757
US

IV. Provider business mailing address

20829 HIGHWAY 6 AND 19
SAEGERTOWN PA
16433-4145
US

V. Phone/Fax

Practice location:
  • Phone: 814-333-5061
  • Fax: 814-333-5067
Mailing address:
  • Phone: 814-398-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC004060
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: