Provider Demographics
NPI:1780029165
Name:DICKERSON, JOSEPH LEE JR (M ED)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:LEE
Last Name:DICKERSON
Suffix:JR
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2415
Mailing Address - Country:US
Mailing Address - Phone:860-882-9117
Mailing Address - Fax:
Practice Address - Street 1:872 VERNON ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2415
Practice Address - Country:US
Practice Address - Phone:860-882-9117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTC022013000914101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional