Basic Information
| Provider Information | |||||||||
| NPI: | 1336790716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DICKERSON | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 PAREV WAY | ||||||||
| Address2: | |||||||||
| City: | UPPER MARLBORO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207741691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3015036332 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1900 N HOWARD ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212185909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4434386742 | ||||||||
| FaxNumber: | 4437735624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2019 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LC13079 | MD | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 38-3876389 | 05 | MD | MEDICAID |