Provider Demographics
NPI:1518597129
Name:DIXON, BUFFET M
Entity Type:Individual
Prefix:
First Name:BUFFET
Middle Name:M
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 1:8511 LEFFERTS BLVD APT 5F
Mailing Address - Street 2:
Mailing Address - City:KEW GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11415-3038
Mailing Address - Country:US
Mailing Address - Phone:917-544-9453
Mailing Address - Fax:
Practice Address - Street 1:8511 LEFFERTS BLVD APT 5F
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3038
Practice Address - Country:US
Practice Address - Phone:917-544-9453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107609104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker