Provider Demographics
NPI:1013443043
Name:DICKERT, TAYLOR (LLMSW)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:DICKERT
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 1:715 TERRACE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440-1105
Mailing Address - Country:US
Mailing Address - Phone:231-830-9376
Mailing Address - Fax:
Practice Address - Street 1:480 BENNETT ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442
Practice Address - Country:US
Practice Address - Phone:231-733-6709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104820104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1013443043Medicaid