Provider Demographics
NPI:1306134275
Name:DICKSON, KYOUNG HI SONG (LMFT)
Entity type:Individual
Prefix:MS
First Name:KYOUNG HI
Middle Name:SONG
Last Name:DICKSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 KELLEY STREET
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-314-1236
Mailing Address - Fax:860-314-1236
Practice Address - Street 1:38 KELLEY ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5715
Practice Address - Country:US
Practice Address - Phone:860-314-1236
Practice Address - Fax:860-314-1236
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001459106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist