Provider Demographics
NPI:1619442712
Name:DIX, CHANTE NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:CHANTE
Middle Name:NICOLE
Last Name:DIX
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 EAGLE TRACE CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:644 TALLULAH TRL
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7625
Practice Address - Country:US
Practice Address - Phone:770-539-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-31562103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst