Provider Demographics
NPI:1568887339
Name:DICKERSON, GREGORY (LCSW)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4477 W EMERALD ST
Mailing Address - Street 2:SUITE C100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2000
Mailing Address - Country:US
Mailing Address - Phone:208-321-0160
Mailing Address - Fax:208-321-0221
Practice Address - Street 1:4477 W EMERALD ST
Practice Address - Street 2:SUITE C100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2000
Practice Address - Country:US
Practice Address - Phone:208-321-0160
Practice Address - Fax:208-321-0221
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-420761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical