Provider Demographics
NPI:1225361603
Name:DICKSON, GREGORY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:L
Last Name:DICKSON
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 1:9404 GENESEE AVE
Mailing Address - Street 2:SUITE 335
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1339
Mailing Address - Country:US
Mailing Address - Phone:858-350-7627
Mailing Address - Fax:
Practice Address - Street 1:9404 GENESEE AVE.
Practice Address - Street 2:SUITE 335
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9203
Practice Address - Country:US
Practice Address - Phone:858-350-7637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY-16565103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical