Provider Demographics
NPI:1417327610
Name:IVERSON, DIXINE D (COTA)
Entity Type:Individual
Prefix:
First Name:DIXINE
Middle Name:D
Last Name:IVERSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42888 GOLF VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-2009
Mailing Address - Country:US
Mailing Address - Phone:540-520-8623
Mailing Address - Fax:
Practice Address - Street 1:42888 GOLF VIEW DR
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-2009
Practice Address - Country:US
Practice Address - Phone:540-520-8623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131000565224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant