Provider Demographics
NPI:1649925090
Name:DICKERSON, ETHEL (LCSW)
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ETHEL
Other - Middle Name:
Other - Last Name:DICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:135 ELDRIDGE ST UNIT D
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6197
Mailing Address - Country:US
Mailing Address - Phone:860-888-0800
Mailing Address - Fax:
Practice Address - Street 1:135 ELDRIDGE ST UNIT D
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6197
Practice Address - Country:US
Practice Address - Phone:860-888-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0059541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical