Provider Demographics
NPI:1568931293
Name:DICKINSON, LEON LANSING
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:LANSING
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 BOYD ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3522
Mailing Address - Country:US
Mailing Address - Phone:315-788-2835
Mailing Address - Fax:
Practice Address - Street 1:482 BLACK RIVER PKWY
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2416
Practice Address - Country:US
Practice Address - Phone:315-782-1777
Practice Address - Fax:315-785-8628
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-000860101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY18-000860OtherNEW YORK STATE DEPARTMENT OF EDUCATION