Provider Demographics
NPI:1073734109
Name:DICKSON ANDERSEN, MARY A (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:DICKSON ANDERSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:316 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2154
Mailing Address - Country:US
Mailing Address - Phone:732-219-0737
Mailing Address - Fax:732-530-5446
Practice Address - Street 1:316 BROAD ST
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2154
Practice Address - Country:US
Practice Address - Phone:732-219-0737
Practice Address - Fax:732-530-5446
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC003708001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0835421Medicare ID - Type Unspecified