Provider Demographics
NPI:1861617052
Name:CANDICE RICHARDSON DICKENS
Entity type:Organization
Organization Name:CANDICE RICHARDSON DICKENS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:RICHARDSON
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, LCADC, NCC
Authorized Official - Phone:410-744-4204
Mailing Address - Street 1:7859 PADDOCK WAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21244-1290
Mailing Address - Country:US
Mailing Address - Phone:410-744-4204
Mailing Address - Fax:410-744-4203
Practice Address - Street 1:5602 BALTIMORE NATIONAL PIKE
Practice Address - Street 2:307
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-1411
Practice Address - Country:US
Practice Address - Phone:410-744-4204
Practice Address - Fax:410-744-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-15
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA214101YA0400X
DCPRC13709101YM0800X
MDLC0686101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6895026 00Medicaid
MD6895026 00Medicaid
2137292Medicare UPIN
474855Medicare UPIN
100086595001Medicare UPIN
364643Medicare UPIN
6902000000436CMedicare UPIN
3968280Medicare UPIN
M543001Medicare UPIN
7234685Medicare UPIN
789109000Medicare UPIN