=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700208626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON DICKSON PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2014
-----------------------------------------------------
Last Update Date | 01/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 534 ANGELL ST
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-4414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-331-1364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 523 WAYLAND AVE
-----------------------------------------------------
City | PROVIDENCE
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02906-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-573-5821
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PS01327
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------