Provider Demographics
NPI:1831534213
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?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
CT3221101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty