Provider Demographics
NPI:1962178806
Name:DYSON, MICHAEL JEMAR (LCMHC-A, NCC, CCC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JEMAR
Last Name:DYSON
Suffix:
Gender:M
Credentials:LCMHC-A, NCC, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081-4248
Mailing Address - Country:US
Mailing Address - Phone:704-493-5756
Mailing Address - Fax:
Practice Address - Street 1:1074 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081-4248
Practice Address - Country:US
Practice Address - Phone:704-493-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-20
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16627101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health