MEDICARE: DR. KELLY A DICKINSON PH. D.

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	103TC0700X	Clinical Psychologist	PY3728	WA

General Provider Information

NPI Number	:	1841221207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY A DICKINSON PH. D.

Provider Business Mailing Address
First Line	:	32020 32ND AVE S STE 110
Second Line	:
City	:	FEDERAL WAY
State	:	WA
Zip	:	98001-9349
Country	:	US
Telephone Number	:	253-838-3090
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 W RIVERSIDE AVE # 6728
Second Line	:
City	:	SPOKANE
State	:	WA
Zip	:	99201-0580
Country	:	US
Telephone Number	:	253-553-3483
Fax Number	:

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

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	04/26/2025

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