Provider Demographics
NPI:1033686324
Name:DICKSON, CANDICE J
Entity Type:Individual
Prefix:MISS
First Name:CANDICE
Middle Name:J
Last Name:DICKSON
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 1:136 GREEN ACRES RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-1506
Mailing Address - Country:US
Mailing Address - Phone:516-445-1675
Mailing Address - Fax:
Practice Address - Street 1:116 W 32ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3212
Practice Address - Country:US
Practice Address - Phone:212-564-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102437-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker