Provider Demographics
NPI:1366516759
Name:DICKERSON, DAWN W (LPCC)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:W
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50369
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87181-0369
Mailing Address - Country:US
Mailing Address - Phone:505-450-6175
Mailing Address - Fax:505-292-6336
Practice Address - Street 1:1809 MOON ST NE
Practice Address - Street 2:SUITE 3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2850
Practice Address - Country:US
Practice Address - Phone:505-450-6175
Practice Address - Fax:505-292-6336
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0065612101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13632345Medicaid