Provider Demographics
NPI:1003465873
Name:DIXIE, RAPHILLA D
Entity Type:Individual
Prefix:
First Name:RAPHILLA
Middle Name:D
Last Name:DIXIE
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 1:3005 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-4736
Mailing Address - Country:US
Mailing Address - Phone:260-267-9498
Mailing Address - Fax:
Practice Address - Street 1:3005 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4736
Practice Address - Country:US
Practice Address - Phone:260-267-9498
Practice Address - Fax:260-739-3618
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001756A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)