Provider Demographics
NPI:1275234924
Name:DICKERSON, ERIENCE REID SR
Entity Type:Individual
Prefix:
First Name:ERIENCE
Middle Name:REID
Last Name:DICKERSON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3621
Mailing Address - Country:US
Mailing Address - Phone:718-845-2621
Mailing Address - Fax:
Practice Address - Street 1:694 20TH STREET FAR ROCKAWAY NY
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY QUEENS
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:646-818-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health