Provider Demographics
NPI:1003922543
Name:DICKERSON, DEIDRE SUE (MSW)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:SUE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4081
Mailing Address - Country:US
Mailing Address - Phone:864-229-7120
Mailing Address - Fax:
Practice Address - Street 1:1547 PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-223-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid