1366544553 NPI number — MR. MARC T DICKER PAC, LCPC

Table of content: MR. MARC T DICKER PAC, LCPC (NPI 1366544553)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366544553 NPI number — MR. MARC T DICKER PAC, LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKER
Provider First Name:
MARC
Provider Middle Name:
T
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PAC, LCPC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366544553
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7829 E ROCKHILL ST
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67206-3920
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-686-5195
Provider Business Mailing Address Fax Number:
316-686-8714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7829 E ROCKHILL ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67206-3920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-686-5195
Provider Business Practice Location Address Fax Number:
316-686-8714
Provider Enumeration Date:
09/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LCPC-127 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA-15-00156 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363AM0700X , with the licence number: PA-15-00156 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100352880A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".