Provider Demographics
NPI:1043722283
Name:DIXON, SABRA MARY (LSUDC)
Entity Type:Individual
Prefix:
First Name:SABRA
Middle Name:MARY
Last Name:DIXON
Suffix:
Gender:F
Credentials:LSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 N 180 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4566
Mailing Address - Country:US
Mailing Address - Phone:801-427-9726
Mailing Address - Fax:
Practice Address - Street 1:591 W 800 N
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-3762
Practice Address - Country:US
Practice Address - Phone:801-427-9726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10181747-6005101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)