Provider Demographics
NPI:1174053052
Name:DICKSON, DEREK JAMES (LPC)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:JAMES
Last Name:DICKSON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 OMALLEY DR APT 302
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2070
Mailing Address - Country:US
Mailing Address - Phone:740-221-3841
Mailing Address - Fax:
Practice Address - Street 1:3929 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111
Practice Address - Country:US
Practice Address - Phone:216-252-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health