Provider Demographics
NPI:1598319626
Name:DICKER, RENEE (RADT)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:DICKER
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 MCHENRY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1451
Mailing Address - Country:US
Mailing Address - Phone:209-523-6910
Mailing Address - Fax:209-523-6912
Practice Address - Street 1:3125 MCHENRY AVE STE D
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1451
Practice Address - Country:US
Practice Address - Phone:209-523-6910
Practice Address - Fax:209-523-6912
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1341540319101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)