Provider Demographics
NPI:1669480869
Name:DICKSON, ANDREW L (PHD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:L
Last Name:DICKSON
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 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-268-5620
Mailing Address - Fax:601-268-5851
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5620
Practice Address - Fax:601-268-5851
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS8104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1559323OtherAMERICAN ADMIN GROUP
260027218OtherRAILROAD MEDICARE
MS00124964Medicaid
R34925Medicare UPIN
MS1559323OtherAMERICAN ADMIN GROUP