Provider Demographics
NPI:1518057975
Name:DICKERSON, PAULINE (LSW)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1208
Mailing Address - Country:US
Mailing Address - Phone:701-328-8819
Mailing Address - Fax:701-328-8900
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1208
Practice Address - Country:US
Practice Address - Phone:701-328-8819
Practice Address - Fax:701-328-8900
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2400104100000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17857OtherBCBS