Provider Demographics
NPI:1861565772
Name:DICKSON, AGNES C (PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:AGNES
Middle Name:C
Last Name:DICKSON
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1538 BROOKHOLLOW DR STE E
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-5452
Mailing Address - Country:US
Mailing Address - Phone:714-751-7789
Mailing Address - Fax:714-751-7791
Practice Address - Street 1:1538 BROOKHOLLOW DR STE E
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-5452
Practice Address - Country:US
Practice Address - Phone:714-751-7789
Practice Address - Fax:714-751-7791
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 12015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP12015AMedicare ID - Type UnspecifiedMEDICARE