Provider Demographics
NPI:1871273912
Name:DICKINSON, KRISTEN NOELLE
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:NOELLE
Last Name:DICKINSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15933 S CODO DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-7924
Mailing Address - Country:US
Mailing Address - Phone:610-223-7911
Mailing Address - Fax:
Practice Address - Street 1:300 READ ST STE A
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-3265
Practice Address - Country:US
Practice Address - Phone:708-996-0774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-24
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150110894104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker