Provider Demographics
NPI:1497137897
Name:DICKSON, SHADE
Entity Type:Individual
Prefix:
First Name:SHADE
Middle Name:
Last Name:DICKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 TARA DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08094-3591
Mailing Address - Country:US
Mailing Address - Phone:856-262-1200
Mailing Address - Fax:856-262-1204
Practice Address - Street 1:1330 N BLACK HORSE PIKE
Practice Address - Street 2:SUITE D
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-9160
Practice Address - Country:US
Practice Address - Phone:856-262-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ474254341171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ474254341Medicaid