MEDICARE: THOMAS DICKEY MFT

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	106H00000X	Marriage & Family Therapist	MFC 32853	CA

General Provider Information

NPI Number	:	1457393449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THOMAS DICKEY MFT

Provider Business Mailing Address
First Line	:	PO BOX 13266
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96151-3266
Country	:	US
Telephone Number	:	530-543-0400
Fax Number	:	530-543-1209

Provider Business Practice Location Address
First Line	:	2489 LAKE TAHOE BLVD
Second Line	:	STE 26
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-7728
Country	:	US
Telephone Number	:	530-543-0400
Fax Number	:	530-543-1209

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

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	07/08/2007

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