MEDICARE: SHIRLECIA J DICKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor	89645	TX

General Provider Information

NPI Number	:	1144080979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIRLECIA J DICKSON

Provider Business Mailing Address
First Line	:	4373 LAGUARDIA LN APT 6204
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3526
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4373 LAGUARDIA LN APT 6204
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76155-3526
Country	:	US
Telephone Number	:	469-386-5353
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	04/05/2024

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