Provider Demographics
NPI:1780816603
Name:DICKERSON, KATHERINE RUTH (LCMHCS, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:RUTH
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCMHCS, LCAS, CCS
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:R
Other - Last Name:PEDRAZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LCAS
Mailing Address - Street 1:7490 WATERSIDE CROSSING BLVD STE 2A
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-3004
Mailing Address - Country:US
Mailing Address - Phone:704-360-3637
Mailing Address - Fax:704-625-9789
Practice Address - Street 1:7490 WATERSIDE CROSSING BLVD STE 2A
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-3004
Practice Address - Country:US
Practice Address - Phone:704-360-3637
Practice Address - Fax:704-625-9789
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-1406101YA0400X
NCCCS-10965101YA0400X, 101YM0800X
NCS9956101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3112086Medicaid