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General NPI Number Information
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NPI Number | 1023241924
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Entity Type | Individual
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Provider Name | KELLY S DICKSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/26/2009
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Last Update Date | 06/15/2020
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Provider Practice Location Address
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Address Line | 7 MUNICIPAL WAY
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City | EDGEWOOD
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State | NM
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Zip | 87015
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Country | US
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Telephone | 505-873-7462
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Fax |
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Provider Business Mailing Address
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Address Line | 7 MUNICIPAL WAY FIRST CHOICE COMMUNITY HEALTHCARE, INC
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City | EDGEWOOD
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State | NM
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Zip | 87015-7086
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Country | US
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Telephone | 505-873-7462
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Fax | 505-241-5188
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | M-08815
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C-10136
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License Number State | NM
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