Provider Demographics
NPI:1215253109
Name:DICKERHOOF, EDWARD E (PCC - S)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:E
Last Name:DICKERHOOF
Suffix:
Gender:M
Credentials:PCC - S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4572 DRESSLER RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2546
Mailing Address - Country:US
Mailing Address - Phone:330-493-4220
Mailing Address - Fax:
Practice Address - Street 1:4572 DRESSLER RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2546
Practice Address - Country:US
Practice Address - Phone:330-493-4220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE. 0500701 SUPV101Y00000X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional