Provider Demographics
NPI:1114401759
Name:DICKERSON, ASHA S (PHD, LPC, NCC, CPCS)
Entity Type:Individual
Prefix:DR
First Name:ASHA
Middle Name:S
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PHD, LPC, NCC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28551
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30358-0551
Mailing Address - Country:US
Mailing Address - Phone:404-904-9188
Mailing Address - Fax:
Practice Address - Street 1:10 CROSS CREEK DR
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-7054
Practice Address - Country:US
Practice Address - Phone:404-904-9188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008339101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor