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General NPI Number Information
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NPI Number | 1386930733
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Entity Type | Individual
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Provider Name | THAD SHANE DICKSON CPHIMS, PMP
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Gender | Male
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Dates
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Enumeration Date | 06/23/2011
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Last Update Date | 05/07/2014
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Provider Practice Location Address
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Address Line | 16511 34TH STREET KP N
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City | LAKEBAY
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State | WA
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Zip | 98349-9774
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Country | US
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Telephone | 253-651-7482
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Fax |
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Provider Business Mailing Address
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Address Line | 16511 34TH STREET KP N
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City | LAKEBAY
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State | WA
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Zip | 98349-9774
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Country | US
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Telephone | 253-651-7482
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Fax |
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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 | 246Z00000X
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Taxonomy Name | Other Specialist/Technologist
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License Number | CPHIMS - 1592
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | WA
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