Provider Demographics
NPI:1336917533
Name:ALICEA, DICKSON
Entity Type:Individual
Prefix:
First Name:DICKSON
Middle Name:
Last Name:ALICEA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 DEN RIC DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5489
Mailing Address - Country:US
Mailing Address - Phone:770-349-5735
Mailing Address - Fax:
Practice Address - Street 1:245 DEN RIC DR
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5489
Practice Address - Country:US
Practice Address - Phone:770-349-5735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101Y00000XBehavioral Health & Social Service ProvidersCounselor