Provider Demographics
NPI:1619349925
Name:DICKERSON, KENDRA
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:FANWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07023-0185
Mailing Address - Country:US
Mailing Address - Phone:646-260-3875
Mailing Address - Fax:
Practice Address - Street 1:95 FARLEY AVE
Practice Address - Street 2:
Practice Address - City:FANWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07023-1004
Practice Address - Country:US
Practice Address - Phone:646-260-3875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst