Provider Demographics
NPI:1023377991
Name:DICKE, JOHN A (PSYD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:DICKE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 KALISA WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-3508
Mailing Address - Country:US
Mailing Address - Phone:888-948-6789
Mailing Address - Fax:877-345-3501
Practice Address - Street 1:3701 W RADCLIFF AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80236-3645
Practice Address - Country:US
Practice Address - Phone:888-948-6789
Practice Address - Fax:877-345-3501
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1980103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1980OtherSTATE LICENSE
CO11366428OtherCAQH PIN
CO07019805Medicaid
CO1980OtherSTATE LICENSE