Provider Demographics
NPI:1932201126
Name:DICKINSON, ADA (MA LMHC ATR BC)
Entity Type:Individual
Prefix:MS
First Name:ADA
Middle Name:
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:MA LMHC ATR BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805
Mailing Address - Country:US
Mailing Address - Phone:260-471-2300
Mailing Address - Fax:260-471-2778
Practice Address - Street 1:3010 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-471-2300
Practice Address - Fax:260-471-2778
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39000397A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000248937OtherANTHEM
294323OtherTRICARE