Provider Demographics
NPI:1275903924
Name:DICKERSON, TERRI (CADC)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 TACKETT BOTTOM RD
Mailing Address - Street 2:
Mailing Address - City:SALYERSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41465
Mailing Address - Country:US
Mailing Address - Phone:859-209-2360
Mailing Address - Fax:
Practice Address - Street 1:505 HECKS PLAZA
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351
Practice Address - Country:US
Practice Address - Phone:859-209-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1260101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1260Medicaid