Provider Demographics
NPI:1124604251
Name:DIXON, WILMA
Entity Type:Individual
Prefix:
First Name:WILMA
Middle Name:
Last Name:DIXON
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 1:613 MARQUETTE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-3038
Mailing Address - Country:US
Mailing Address - Phone:601-825-8800
Mailing Address - Fax:
Practice Address - Street 1:466 OLD WHITFIELD RD
Practice Address - Street 2:
Practice Address - City:PEARL
Practice Address - State:MS
Practice Address - Zip Code:39208-9148
Practice Address - Country:US
Practice Address - Phone:601-613-1707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional