Provider Demographics
NPI:1194831305
Name:DICKSON, PATRICIA KOESTER (PHD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:KOESTER
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19900 E 10 MILE RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-4412
Mailing Address - Country:US
Mailing Address - Phone:586-776-3366
Mailing Address - Fax:586-776-3369
Practice Address - Street 1:19900 E 10 MILE RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-4412
Practice Address - Country:US
Practice Address - Phone:586-776-3366
Practice Address - Fax:586-776-3369
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007372103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M9770Medicare ID - Type Unspecified