Provider Demographics
NPI:1811524382
Name:DICKENSON, PHYLLIS ANN
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:ANN
Last Name:DICKENSON
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 1:2105 112TH AVE NE STE 200
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-2945
Mailing Address - Country:US
Mailing Address - Phone:408-761-3766
Mailing Address - Fax:
Practice Address - Street 1:2105 112TH AVE NE STE 200
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2945
Practice Address - Country:US
Practice Address - Phone:408-761-3766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC61033567101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health