Provider Demographics
NPI:1558875997
Name:DIXON, CAROLYN R (LSW, LCDCIII)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:R
Last Name:DIXON
Suffix:
Gender:F
Credentials:LSW, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:547 E 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-2603
Mailing Address - Country:US
Mailing Address - Phone:614-224-4506
Mailing Address - Fax:614-291-0118
Practice Address - Street 1:547 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211
Practice Address - Country:US
Practice Address - Phone:614-224-4506
Practice Address - Fax:614-291-0118
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.161663101YA0400X
OHS.1801990104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0265046Medicaid