Provider Demographics
NPI:1760545354
Name:DIXON, STACEY L (PHD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
Last Name:DIXON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 UNION AVE
Mailing Address - Street 2:SUITE 315
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3921
Mailing Address - Country:US
Mailing Address - Phone:901-726-1284
Mailing Address - Fax:901-726-4396
Practice Address - Street 1:917 S COOPER ST
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-5606
Practice Address - Country:US
Practice Address - Phone:901-336-6975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1815103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3684937Medicare ID - Type Unspecified