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General NPI Number Information
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NPI Number | 1487661757
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Entity Type | Individual
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Provider Name | JOAN P DICKERSON M.S.,LCSW, LMFT, LPC
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Gender | Female
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 11/04/2011
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Provider Practice Location Address
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Address Line | 3333 N MAYFAIR RD SUITE 210
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City | WAUWATOSA
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State | WI
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Zip | 53222-3219
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Country | US
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Telephone | 414-750-8033
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Fax | 414-778-1531
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Provider Business Mailing Address
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Address Line | P. O. BOX 593
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City | STURTEVANT
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State | WI
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Zip | 53177-0593
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Country | US
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Telephone | 414-750-8033
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Fax | 414-778-1531
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 340-125
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License Number State | WI
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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 | 1178-123
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License Number State | WI
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Taxonomy #3
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 391-124
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License Number State | WI
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