Provider Demographics
NPI:1689757429
Name:DICKINSON, MARDELL (LPC)
Entity Type:Individual
Prefix:
First Name:MARDELL
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:LPC
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 74816
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-4816
Mailing Address - Country:US
Mailing Address - Phone:907-460-2166
Mailing Address - Fax:
Practice Address - Street 1:1716 UNIVERSITY AVE S
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4904
Practice Address - Country:US
Practice Address - Phone:907-460-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK376101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional