Provider Demographics
NPI:1336790716
Name:DICKERSON, NATHAN JR (LCPC)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:DICKERSON
Suffix:JR
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 675366
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-5366
Mailing Address - Country:US
Mailing Address - Phone:410-757-2077
Mailing Address - Fax:
Practice Address - Street 1:8258 VETERANS HWY STE 13
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1564
Practice Address - Country:US
Practice Address - Phone:410-768-6088
Practice Address - Fax:410-768-6444
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC13079101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38-3876389Medicaid