Provider Demographics
NPI:1174992531
Name:DICKERSON, SHANICE NICOLE
Entity type:Individual
Prefix:
First Name:SHANICE
Middle Name:NICOLE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 RACETRACK RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-1022
Mailing Address - Country:US
Mailing Address - Phone:912-548-9944
Mailing Address - Fax:
Practice Address - Street 1:382 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-1022
Practice Address - Country:US
Practice Address - Phone:912-548-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042611055OtherTAX ID
MA99618201OtherNETWORK HEALTH
MA1004745OtherFALLON
MA0000023532OtherBMC
MA1004745OtherNHP
MAM18633OtherBCBS
MA1303287OtherMBHP