Provider Demographics
NPI:1548601990
Name:DICKOUT, MARY ELIZABETH ANN (BA,CPRP)
Entity Type:Individual
Prefix:MRS
First Name:MARY ELIZABETH
Middle Name:ANN
Last Name:DICKOUT
Suffix:
Gender:F
Credentials:BA,CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3763 EVANS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9302
Mailing Address - Country:US
Mailing Address - Phone:239-931-9827
Mailing Address - Fax:239-332-6985
Practice Address - Street 1:3763 EVANS AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-9302
Practice Address - Country:US
Practice Address - Phone:239-332-6937
Practice Address - Fax:239-332-6985
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171637101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor