Provider Demographics
NPI:1760867600
Name:DICKENS, AUGUSTUS
Entity Type:Individual
Prefix:
First Name:AUGUSTUS
Middle Name:
Last Name:DICKENS
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 1:1417 WINTER PINE TRL
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1506
Mailing Address - Country:US
Mailing Address - Phone:301-257-1430
Mailing Address - Fax:
Practice Address - Street 1:1417 WINTER PINE TRL
Practice Address - Street 2:
Practice Address - City:SEVERN
Practice Address - State:MD
Practice Address - Zip Code:21144-1506
Practice Address - Country:US
Practice Address - Phone:301-257-1430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC6378101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health