Provider Demographics
NPI:1972179620
Name:DICKENSON, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DICKENSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-2454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-2454
Practice Address - Country:US
Practice Address - Phone:812-220-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)