Healthcare Provider Details

I. General information

NPI: 1194804054
Provider Name (Legal Business Name): SUSANE A. DICKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 VETERANS MEMORIAL PKWY
RIVERSIDE RI
02915-5061
US

IV. Provider business mailing address

117 ELLENFIELD ST STE 101
PROVIDENCE RI
02905-4541
US

V. Phone/Fax

Practice location:
  • Phone: 401-432-1000
  • Fax: 401-432-1500
Mailing address:
  • Phone: 14-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number264742
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME71623
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD17188
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: