1215157045 NPI number — DR. CARL THOMAS DICKERSON LPC

Table of content: DR. CARL THOMAS DICKERSON LPC (NPI 1215157045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215157045 NPI number — DR. CARL THOMAS DICKERSON LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DICKERSON
Provider First Name:
CARL
Provider Middle Name:
THOMAS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1215157045
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/06/2020
NPI Reactivation Date:
08/12/2020

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1595 PEACHTREE PKWY, STE 204, # 227
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUMMING
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30041-2040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-431-2070
Provider Business Mailing Address Fax Number:
470-281-5383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1595 PEACHTREE PKWY, STE 204, # 227
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUMMING
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30041-2040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-431-2070
Provider Business Practice Location Address Fax Number:
470-281-5711
Provider Enumeration Date:
04/26/2007

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: 101YP2500X , with the licence number:  0323 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: LPC010077 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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