Provider Demographics
NPI:1982190674
Name:DICKINSON, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DICKINSON
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 1:156 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-7314
Mailing Address - Country:US
Mailing Address - Phone:302-674-2380
Mailing Address - Fax:302-674-1299
Practice Address - Street 1:118 SANDHILL DR STE 202
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:DE
Practice Address - Zip Code:19709-5863
Practice Address - Country:US
Practice Address - Phone:302-674-2380
Practice Address - Fax:302-674-1299
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD483106300Medicaid