Provider Demographics
NPI:1780783761
Name:DICKSON-RISHEL, DOROTHY (PHD)
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:DICKSON-RISHEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1810
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39502-1810
Mailing Address - Country:US
Mailing Address - Phone:228-864-8454
Mailing Address - Fax:228-865-1457
Practice Address - Street 1:1340 BROAD AVE
Practice Address - Street 2:SUITE 450
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2404
Practice Address - Country:US
Practice Address - Phone:228-867-5006
Practice Address - Fax:228-867-5079
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33507103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113112Medicaid
MS00113112Medicaid
MS680000158Medicare PIN