Provider Demographics
NPI:1053409722
Name:DICKERSON, LATREECE EVETTE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LATREECE
Middle Name:EVETTE
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9933 S WESTERN AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1810
Mailing Address - Country:US
Mailing Address - Phone:312-730-3966
Mailing Address - Fax:312-803-1635
Practice Address - Street 1:9933 S WESTERN AVE STE 203
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1810
Practice Address - Country:US
Practice Address - Phone:312-730-3966
Practice Address - Fax:312-803-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0085201041C0700X
IL071009102103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1437667805OtherPARTNERSHIPS IN BEHAVIORAL HEALTH