Provider Demographics
NPI:1629033113
Name:DICKINSON, DWIGHT (PHD,)
Entity Type:Individual
Prefix:DR
First Name:DWIGHT
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N GREEN STREET
Mailing Address - Street 2:VISN 5 MIRECC SUITE 6A (BT/MIRECC)
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-1524
Mailing Address - Country:US
Mailing Address - Phone:410-605-7817
Mailing Address - Fax:410-605-7739
Practice Address - Street 1:10 N GREEN STREET
Practice Address - Street 2:VISN 5 MIRECC SUITE 6A (BT/MIRECC)
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1524
Practice Address - Country:US
Practice Address - Phone:410-605-7817
Practice Address - Fax:410-605-7739
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03997103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist