Individual
SHANICE NICOLE DICKERSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
382 RACETRACK RD, MCDONOUGH, GA 30252-1022
(912) 548-9944
Mailing address
382 RACETRACK RD, MCDONOUGH, GA 30252-1022
(912) 548-9944
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0000023532
BMC
MA
01
—
042611055
TAX ID
MA
01
—
1004745
FALLON
MA
01
—
1303287
MBHP
MA
01
—
99618201
NETWORK HEALTH
MA
01
—
M18633
BCBS
MA
Enumeration date
09/16/2015
Last updated
11/12/2021
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