Provider Demographics
NPI:1386930733
Name:DICKSON, THAD SHANE (CPHIMS, PMP)
Entity type:Individual
Prefix:
First Name:THAD
Middle Name:SHANE
Last Name:DICKSON
Suffix:
Gender:M
Credentials:CPHIMS, PMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16511 34TH STREET KP N
Mailing Address - Street 2:
Mailing Address - City:LAKEBAY
Mailing Address - State:WA
Mailing Address - Zip Code:98349-9774
Mailing Address - Country:US
Mailing Address - Phone:253-651-7482
Mailing Address - Fax:
Practice Address - Street 1:16511 34TH STREET KP N
Practice Address - Street 2:
Practice Address - City:LAKEBAY
Practice Address - State:WA
Practice Address - Zip Code:98349-9774
Practice Address - Country:US
Practice Address - Phone:253-651-7482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACPHIMS - 1592246Z00000X
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADICKSTS PMPOtherPMP
WA451268OtherHCISSP
WA1592OtherCPHIMS