Provider Demographics
NPI:1306197603
Name:DICKENS, THEODORE JOSEPH JR (LCSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOSEPH
Last Name:DICKENS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4009 HENICAN PL
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70003-1309
Mailing Address - Country:US
Mailing Address - Phone:504-610-7722
Mailing Address - Fax:
Practice Address - Street 1:4009 HENICAN PL
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003-1309
Practice Address - Country:US
Practice Address - Phone:504-610-7722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA47581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical