Provider Demographics
NPI:1740923267
Name:DICKERSON, TIISHA (LCPC)
Entity type:Individual
Prefix:
First Name:TIISHA
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:TIISHA
Other - Middle Name:
Other - Last Name:TOWNSEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:901 N 1ST ST STE 225
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-3760
Mailing Address - Country:US
Mailing Address - Phone:217-788-4065
Mailing Address - Fax:217-757-7550
Practice Address - Street 1:901 N 1ST ST STE 225
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-3760
Practice Address - Country:US
Practice Address - Phone:217-788-4065
Practice Address - Fax:217-788-4147
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.016038101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1750614798OtherMCA NPI