Provider Demographics
NPI:1902414808
Name:DICKEY, KHADIJAH CHELSI
Entity Type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:CHELSI
Last Name:DICKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KHADIJAH
Other - Middle Name:CHELSI
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1321 MURFREESBORO PIKE STE 702
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37217-2679
Mailing Address - Country:US
Mailing Address - Phone:615-695-2277
Mailing Address - Fax:317-520-8200
Practice Address - Street 1:613 STEPHENSON AVE STE 206
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5841
Practice Address - Country:US
Practice Address - Phone:912-349-2479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-127723106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician