Provider Demographics
NPI:1255650800
Name:DICKINSON, MERCEDES (PHD)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:
Last Name:DICKINSON
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 1:308 WINDSOR AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8052
Mailing Address - Country:US
Mailing Address - Phone:832-729-7687
Mailing Address - Fax:
Practice Address - Street 1:1744 E MCANDREWS RD STE J
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-5576
Practice Address - Country:US
Practice Address - Phone:832-729-7687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2052103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical