Provider Demographics
NPI:1063928794
Name:DICKSON, GEORGE LEWIS (LSW)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:LEWIS
Last Name:DICKSON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41191 TOWNSHIP ROAD 78
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-9110
Mailing Address - Country:US
Mailing Address - Phone:740-294-9007
Mailing Address - Fax:
Practice Address - Street 1:209 SENECA AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:BYESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43723-1364
Practice Address - Country:US
Practice Address - Phone:740-685-1610
Practice Address - Fax:740-685-1610
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS20836104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker