Provider Demographics
NPI:1225684871
Name:JOHNSON, DIXIE
Entity Type:Individual
Prefix:
First Name:DIXIE
Middle Name:
Last Name:JOHNSON
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 1:46-1013 EMEPELA WAY APT 19A
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-6909
Mailing Address - Country:US
Mailing Address - Phone:208-550-4666
Mailing Address - Fax:
Practice Address - Street 1:54-046 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:HAUULA
Practice Address - State:HI
Practice Address - Zip Code:96717-9647
Practice Address - Country:US
Practice Address - Phone:208-550-4666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRBT-19-86994106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician