Provider Demographics
NPI:1801171525
Name:DICKERSON, MARY LEE (LCSW)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3063 CULVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14622-2635
Mailing Address - Country:US
Mailing Address - Phone:585-338-7227
Mailing Address - Fax:
Practice Address - Street 1:965 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-3930
Practice Address - Country:US
Practice Address - Phone:585-288-3654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041SO200X1041S0200X
NYRO44519-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool