Provider Demographics
NPI:1669993663
Name:DICKERSON ENTERPRISE LLC
Entity type:Organization
Organization Name:DICKERSON ENTERPRISE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-416-3500
Mailing Address - Street 1:872 VERNON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2415
Mailing Address - Country:US
Mailing Address - Phone:860-416-3500
Mailing Address - Fax:
Practice Address - Street 1:872 VERNON ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2415
Practice Address - Country:US
Practice Address - Phone:860-416-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DICKERSON ENTERPRISE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-29
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3221251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health