Basic Information
| Provider Information | |||||||||
| NPI: | 1366964124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKSON | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | JEAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3304 EMMETT RD | ||||||||
| Address2: | |||||||||
| City: | EMMETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480224511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106898859 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104550102 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2017 | ||||||||
| LastUpdateDate: | 11/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.