Provider Demographics
NPI:1003439928
Name:DICKERSON, KELLY NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JACKSON DICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-1914
Mailing Address - Country:US
Mailing Address - Phone:770-599-7508
Mailing Address - Fax:866-734-7631
Practice Address - Street 1:204 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-1914
Practice Address - Country:US
Practice Address - Phone:770-599-7508
Practice Address - Fax:866-734-7631
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0070861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical