Provider Demographics
NPI:1720584733
Name:DICKEY, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:DICKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12179 LEIF ERICSON DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7724
Mailing Address - Country:US
Mailing Address - Phone:951-567-4657
Mailing Address - Fax:
Practice Address - Street 1:17070 WALNUT VILLAGE PKWY STE K
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3285
Practice Address - Country:US
Practice Address - Phone:909-320-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician