Provider Demographics
NPI:1316313000
Name:DICKERSON, TONY BRIAN (LMFT)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:BRIAN
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43836 STINE RD
Mailing Address - Street 2:
Mailing Address - City:REDWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:13679-4154
Mailing Address - Country:US
Mailing Address - Phone:623-755-1996
Mailing Address - Fax:
Practice Address - Street 1:43836 STINE RD
Practice Address - Street 2:
Practice Address - City:REDWOOD
Practice Address - State:NY
Practice Address - Zip Code:13679-4154
Practice Address - Country:US
Practice Address - Phone:623-755-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001216-1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist