Provider Demographics
NPI:1114107042
Name:DICKSON, MICHAEL A
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:DICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:A
Other - Last Name:DICKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW - ACADC
Mailing Address - Street 1:8100 W EMERALD ST STE 150
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9057
Mailing Address - Country:US
Mailing Address - Phone:208-375-0752
Mailing Address - Fax:208-375-0796
Practice Address - Street 1:8100 W EMERALD ST STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9057
Practice Address - Country:US
Practice Address - Phone:208-375-0752
Practice Address - Fax:208-375-0796
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACADC - 76101YA0400X
IDLCSW - 28518101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)