Provider Demographics
NPI:1659960136
Name:DICKERSON, TIA N (LLMFT, LLPC)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:N
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LLMFT, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 SUNNINGDALE DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1238
Mailing Address - Country:US
Mailing Address - Phone:313-394-9610
Mailing Address - Fax:
Practice Address - Street 1:1056 ORNDORF DR STE G
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-2479
Practice Address - Country:US
Practice Address - Phone:734-386-0041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4151001014106H00000X
MI6451022116101YP2500X
104100000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty