Provider Demographics
NPI:1104342484
Name:DICKENS, DOUG (NCFBPPC)
Entity type:Individual
Prefix:
First Name:DOUG
Middle Name:
Last Name:DICKENS
Suffix:
Gender:M
Credentials:NCFBPPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 S NEW HOPE RD STE 200C
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4870
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 S NEW HOPE RD STE 200C
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4870
Practice Address - Country:US
Practice Address - Phone:704-208-1865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2017-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP1600X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral