Provider Demographics
NPI:1386150639
Name:DICKERSON, BURTON R III (SUBSTANCE ABUSE ADT)
Entity type:Individual
Prefix:MR
First Name:BURTON
Middle Name:R
Last Name:DICKERSON
Suffix:III
Gender:M
Credentials:SUBSTANCE ABUSE ADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:MD
Mailing Address - Zip Code:21921-5996
Mailing Address - Country:US
Mailing Address - Phone:443-406-3234
Mailing Address - Fax:
Practice Address - Street 1:111 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:MD
Practice Address - Zip Code:21921-5996
Practice Address - Country:US
Practice Address - Phone:443-406-3234
Practice Address - Fax:443-406-3234
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1421101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)