Provider Demographics
NPI:1720487770
Name:DICKMAN, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:DICKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E FRONT ST APT B
Mailing Address - Street 2:
Mailing Address - City:NEW BREMEN
Mailing Address - State:OH
Mailing Address - Zip Code:45869-1039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 W HIGH ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2077
Practice Address - Country:US
Practice Address - Phone:419-300-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool