Provider Demographics
NPI:1982383865
Name:DIRICKSON, CALVIN EDWARD
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:EDWARD
Last Name:DIRICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7728 BRAMBLEWOOD DR APT 1B
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8708
Mailing Address - Country:US
Mailing Address - Phone:208-419-8580
Mailing Address - Fax:
Practice Address - Street 1:620 FARM LN RM 213B
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-1600
Practice Address - Country:US
Practice Address - Phone:248-890-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician