Provider Demographics
NPI:1093226409
Name:DICKENS, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DICKENS
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 1:520 PEABODY ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-2028
Mailing Address - Country:US
Mailing Address - Phone:240-899-2896
Mailing Address - Fax:
Practice Address - Street 1:4205 37TH ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:MD
Practice Address - Zip Code:20722-1302
Practice Address - Country:US
Practice Address - Phone:240-899-2896
Practice Address - Fax:240-226-7400
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-12
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8103101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health