Provider Demographics
NPI:1871612119
Name:DICKENSON, NELSON EDDIE (BA , CM , RSS)
Entity type:Individual
Prefix:MR
First Name:NELSON
Middle Name:EDDIE
Last Name:DICKENSON
Suffix:
Gender:M
Credentials:BA , CM , RSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 32-5
Mailing Address - Street 2:
Mailing Address - City:HARTSHORNE
Mailing Address - State:OK
Mailing Address - Zip Code:74547-9700
Mailing Address - Country:US
Mailing Address - Phone:918-297-2495
Mailing Address - Fax:
Practice Address - Street 1:HC 74 BOX 32-5
Practice Address - Street 2:
Practice Address - City:HARTSHORNE
Practice Address - State:OK
Practice Address - Zip Code:74547-9700
Practice Address - Country:US
Practice Address - Phone:918-297-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation