Provider Demographics
NPI:1295203610
Name:DIXON, ANTWAN TAVARIOUS (LPC)
Entity Type:Individual
Prefix:MR
First Name:ANTWAN
Middle Name:TAVARIOUS
Last Name:DIXON
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 SPRINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-4860
Mailing Address - Country:US
Mailing Address - Phone:205-821-6273
Mailing Address - Fax:
Practice Address - Street 1:13 OFFICE PARK CIR STE 19
Practice Address - Street 2:
Practice Address - City:MOUNTAIN BRK
Practice Address - State:AL
Practice Address - Zip Code:35223-2921
Practice Address - Country:US
Practice Address - Phone:205-968-1460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional