Provider Demographics
NPI:1043688807
Name:BLACKWELL, DIXIE LEE (MA SLP)
Entity Type:Individual
Prefix:
First Name:DIXIE
Middle Name:LEE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23222 LA VACA ST
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4523
Mailing Address - Country:US
Mailing Address - Phone:949-244-7247
Mailing Address - Fax:
Practice Address - Street 1:3900 BIRCH ST STE 103
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2226
Practice Address - Country:US
Practice Address - Phone:949-955-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9702235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist