Provider Demographics
NPI:1225857618
Name:DICKERSON, JOANNE ELIZABETH
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:ELIZABETH
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 FORT FLORIDA RD
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-9714
Mailing Address - Country:US
Mailing Address - Phone:386-562-0170
Mailing Address - Fax:
Practice Address - Street 1:454 FORT FLORIDA RD
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-9714
Practice Address - Country:US
Practice Address - Phone:386-562-0170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24-379910106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty