Provider Demographics
NPI:1104984103
Name:AZAR-DICKENS, JOHN (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:AZAR-DICKENS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:DICKENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 6206
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-6206
Mailing Address - Country:US
Mailing Address - Phone:706-232-6743
Mailing Address - Fax:706-232-8050
Practice Address - Street 1:106 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3128
Practice Address - Country:US
Practice Address - Phone:706-232-6743
Practice Address - Fax:706-232-8050
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2459103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00895837Medicaid