Provider Demographics
NPI:1871845412
Name:DICKERSON, WANETA DARCELL (LLMSW)
Entity Type:Individual
Prefix:MS
First Name:WANETA
Middle Name:DARCELL
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 W BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3617
Mailing Address - Country:US
Mailing Address - Phone:313-422-3305
Mailing Address - Fax:
Practice Address - Street 1:169 W. BUENA VISTA
Practice Address - Street 2:
Practice Address - City:HIGHLANDPARK
Practice Address - State:MI
Practice Address - Zip Code:48203
Practice Address - Country:US
Practice Address - Phone:313-422-3305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010948151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical