Provider Demographics
NPI:1487661757
Name:DICKERSON, JOAN P (MS,LCSW, LMFT, LPC)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:P
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MS,LCSW, LMFT, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 593
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0593
Mailing Address - Country:US
Mailing Address - Phone:414-750-8033
Mailing Address - Fax:414-778-1531
Practice Address - Street 1:3333 N MAYFAIR RD
Practice Address - Street 2:SUITE 210
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-3219
Practice Address - Country:US
Practice Address - Phone:414-750-8033
Practice Address - Fax:414-778-1531
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI340-125101YP2500X
WI1178-1231041C0700X
WI391-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40918800Medicaid