Provider Demographics
NPI:1245951417
Name:DICKERSON, KATHERINE MARY
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARY
Last Name:DICKERSON
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 1:97 HILLTOP VILLAGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-3922
Mailing Address - Country:US
Mailing Address - Phone:314-374-1620
Mailing Address - Fax:
Practice Address - Street 1:97 HILLTOP VILLAGE CENTER DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-3922
Practice Address - Country:US
Practice Address - Phone:314-374-1620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional