Provider Demographics
NPI:1144469818
Name:DICKINSON, KERN NEIL (MA)
Entity type:Individual
Prefix:MR
First Name:KERN
Middle Name:NEIL
Last Name:DICKINSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 STATE STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01109
Mailing Address - Country:US
Mailing Address - Phone:508-839-2322
Mailing Address - Fax:508-839-0241
Practice Address - Street 1:576 STATE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01109-4104
Practice Address - Country:US
Practice Address - Phone:508-839-2322
Practice Address - Fax:508-839-0241
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1306839Medicaid