Provider Demographics
NPI:1215157045
Name:DICKERSON, CARL THOMAS (LPC)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:THOMAS
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1595 PEACHTREE PKWY, STE 204, # 227
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-2040
Mailing Address - Country:US
Mailing Address - Phone:678-431-2070
Mailing Address - Fax:470-281-5383
Practice Address - Street 1:1595 PEACHTREE PKWY, STE 204, # 227
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-2040
Practice Address - Country:US
Practice Address - Phone:678-431-2070
Practice Address - Fax:470-281-5711
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2024-04-24
Deactivation Date:2020-08-06
Deactivation Code:
Reactivation Date:2020-08-12
Provider Licenses
StateLicense IDTaxonomies
MS0323101YP2500X
GALPC010077101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional