Provider Demographics
NPI:1174049720
Name:DICKERSON, AL (ASSOC)
Entity type:Individual
Prefix:MR
First Name:AL
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:M
Credentials:ASSOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 S G ST APT 106
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5104
Mailing Address - Country:US
Mailing Address - Phone:253-733-8748
Mailing Address - Fax:
Practice Address - Street 1:815 S PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98465-2117
Practice Address - Country:US
Practice Address - Phone:253-396-5937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health