Provider Demographics
NPI:1346305075
Name:DIXON, KELLY ANGEL
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANGEL
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 1:1017 B-CAPITAL STREET
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590
Mailing Address - Country:US
Mailing Address - Phone:707-315-8324
Mailing Address - Fax:
Practice Address - Street 1:1745 ENTERPRISE DR BLDG 2
Practice Address - Street 2:SUITE I-64
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-5801
Practice Address - Country:US
Practice Address - Phone:707-427-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARW0949101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)