Provider Demographics
NPI:1366743346
Name:DICKERSON, KYLE SCOTT
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:SCOTT
Last Name:DICKERSON
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:PO BOX 7660
Mailing Address - Street 2:
Mailing Address - City:NORCO
Mailing Address - State:CA
Mailing Address - Zip Code:92860-8089
Mailing Address - Country:US
Mailing Address - Phone:760-596-7038
Mailing Address - Fax:
Practice Address - Street 1:15095 AMARGOSA RD STE 201
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92394-1875
Practice Address - Country:US
Practice Address - Phone:760-245-4695
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2019-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203128106H00000X
CA82938106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist