Provider Demographics
NPI:1720597040
Name:DICKEY, LORE M (PHD)
Entity Type:Individual
Prefix:
First Name:LORE
Middle Name:M
Last Name:DICKEY
Suffix:
Gender:F
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:PO BOX 12204
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86011-0428
Mailing Address - Country:US
Mailing Address - Phone:318-265-4287
Mailing Address - Fax:
Practice Address - Street 1:2501 N 4TH ST STE 18D
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3701
Practice Address - Country:US
Practice Address - Phone:318-265-4287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4382103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling