Provider Demographics
NPI:1407357106
Name:DIXON, STEPHANIE LYNN (LSW, CPRP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:DIXON
Suffix:
Gender:F
Credentials:LSW, CPRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 E BEAVER AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16801-4969
Mailing Address - Country:US
Mailing Address - Phone:814-409-7744
Mailing Address - Fax:
Practice Address - Street 1:103 E BEAVER AVE STE 2
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16801-4969
Practice Address - Country:US
Practice Address - Phone:814-409-7744
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW134588104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASW134588OtherLSW