Provider Demographics
NPI:1184732307
Name:DICKERSON, LEE ANNE ANNE (LCP)
Entity type:Individual
Prefix:DR
First Name:LEE ANNE
Middle Name:ANNE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCP
Other - Prefix:DR
Other - First Name:LEE
Other - Middle Name:ANNE
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD/LPC
Mailing Address - Street 1:885 WOODSTOCK ROAD, SUITE 430
Mailing Address - Street 2:#515
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2275
Mailing Address - Country:US
Mailing Address - Phone:757-619-6859
Mailing Address - Fax:
Practice Address - Street 1:555 SUN VALLEY DR STE L1
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5630
Practice Address - Country:US
Practice Address - Phone:404-394-1096
Practice Address - Fax:404-990-3531
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA810003264103T00000X
VA0810003264103TC0700X
GAPSY004236103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC600639Medicaid
VA7714200Medicaid
NC600639Medicaid