Provider Demographics
NPI:1881740694
Name:DICKSON-GILLESPIE, LAURIE M I (PHD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:M
Last Name:DICKSON-GILLESPIE
Suffix:I
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 1:1794 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-2459
Mailing Address - Country:US
Mailing Address - Phone:909-888-1199
Mailing Address - Fax:
Practice Address - Street 1:545 N MOUNTAIN AVE STE 201
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5055
Practice Address - Country:US
Practice Address - Phone:909-946-1326
Practice Address - Fax:909-946-1946
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20914103TC2200X
CA103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool