Provider Demographics
NPI:1528386372
Name:DICKINSON, KELLY SUE (LICSW, LSCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:LICSW, LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-2838
Mailing Address - Country:US
Mailing Address - Phone:913-367-1593
Mailing Address - Fax:913-367-1627
Practice Address - Street 1:201 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-2838
Practice Address - Country:US
Practice Address - Phone:913-367-1593
Practice Address - Fax:913-367-1627
Is Sole Proprietor?:No
Enumeration Date:2010-05-04
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN151561041C0700X
KS42791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN15156OtherLICENSE NUMBER
KS4279OtherLICENSE NUMBER