Provider Demographics
NPI:1790780583
Name:DIXON, LESLIE (MA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N KEEL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3440
Mailing Address - Country:US
Mailing Address - Phone:800-471-8592
Mailing Address - Fax:
Practice Address - Street 1:102 N KEEL RIDGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148-3440
Practice Address - Country:US
Practice Address - Phone:800-471-8592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT-001085-L231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0746376Medicaid
PA0018232190001Medicaid
OH0884191Medicare ID - Type Unspecified
PA0018232190001Medicaid