Provider Demographics
NPI:1427257005
Name:DICKERSON, LAURA (LAC)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 2ND ST E
Mailing Address - Street 2:SUITE 204
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-6107
Mailing Address - Country:US
Mailing Address - Phone:406-752-0530
Mailing Address - Fax:406-752-0534
Practice Address - Street 1:17 2ND ST E
Practice Address - Street 2:SUITE 204
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-6107
Practice Address - Country:US
Practice Address - Phone:406-752-0530
Practice Address - Fax:406-752-0534
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1192 LAC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)