Provider Demographics
NPI:1679280069
Name:DICKERSON, RENEE (LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9633 S PEORIA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1515
Mailing Address - Country:US
Mailing Address - Phone:773-715-1613
Mailing Address - Fax:
Practice Address - Street 1:9633 S PEORIA ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1515
Practice Address - Country:US
Practice Address - Phone:773-715-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004504101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL920571231Medicaid