Provider Demographics
NPI:1669737029
Name:DICKER, DERRICK T (MHS)
Entity type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:T
Last Name:DICKER
Suffix:
Gender:M
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4803 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-4433
Mailing Address - Country:US
Mailing Address - Phone:215-326-9491
Mailing Address - Fax:
Practice Address - Street 1:4803 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-4433
Practice Address - Country:US
Practice Address - Phone:215-326-9491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251S00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health