Provider Demographics
NPI:1760192280
Name:ANTWAN TAVARIOUS DIXON LLC
Entity Type:Organization
Organization Name:ANTWAN TAVARIOUS DIXON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PROF. COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTWAN
Authorized Official - Middle Name:TAVARIOUS
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LPC, NCC
Authorized Official - Phone:800-916-3713
Mailing Address - Street 1:2100 SOUTHBRIDGE PKWY STE 650
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-1317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 SOUTHBRIDGE PKWY STE 650
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-1317
Practice Address - Country:US
Practice Address - Phone:800-916-3713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty