Provider Demographics
NPI:1093760233
Name:DICKINSON, GARY L (PHD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:791 E LAKE HENDRICKS DR
Mailing Address - Street 2:
Mailing Address - City:HENDRICKS
Mailing Address - State:MN
Mailing Address - Zip Code:56136-1204
Mailing Address - Country:US
Mailing Address - Phone:605-271-7690
Mailing Address - Fax:605-479-1349
Practice Address - Street 1:2218 DERDALL DR
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-2851
Practice Address - Country:US
Practice Address - Phone:605-271-7690
Practice Address - Fax:605-479-1349
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD231103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6551103Medicaid
SD4993550OtherWELLMARK BLUECROSS
MN893248400Medicaid
R02729Medicare UPIN
SD4993550OtherWELLMARK BLUECROSS