Provider Demographics
NPI:1376205161
Name:DICKINSON, DANIELLE L (MSSA, LSW)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:L
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:MSSA, LSW
Other - Prefix:
Other - First Name:DYLAN
Other - Middle Name:
Other - Last Name:DICKINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4115 BRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44113-3304
Mailing Address - Country:US
Mailing Address - Phone:216-631-5800
Mailing Address - Fax:
Practice Address - Street 1:4115 BRIDGE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-3304
Practice Address - Country:US
Practice Address - Phone:216-631-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 171M00000X
OHS.2107010104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator