Provider Demographics
NPI:1285119768
Name:DICKSON, KIMBERLY NOELLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:NOELLE
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 N 2ND AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3064
Mailing Address - Country:US
Mailing Address - Phone:209-840-9696
Mailing Address - Fax:
Practice Address - Street 1:145 N 2ND AVE STE 8
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3064
Practice Address - Country:US
Practice Address - Phone:209-840-9696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-01
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30316103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical