Provider Demographics
NPI:1245598002
Name:DIXON, TAWANDA C (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAWANDA
Middle Name:C
Last Name:DIXON
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 QUACCO RD
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-9021
Mailing Address - Country:US
Mailing Address - Phone:864-350-8811
Mailing Address - Fax:912-201-1556
Practice Address - Street 1:2502 QUACCO RD
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-9021
Practice Address - Country:US
Practice Address - Phone:864-350-8811
Practice Address - Fax:912-201-1556
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006875235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist