Provider Demographics
NPI:1821415712
Name:DIXON, NELLY (EDD, BCBA)
Entity Type:Individual
Prefix:DR
First Name:NELLY
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:EDD, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 NEW FREEDOM RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08088-8829
Mailing Address - Country:US
Mailing Address - Phone:609-668-0745
Mailing Address - Fax:
Practice Address - Street 1:104 NEW FREEDOM RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08088-8829
Practice Address - Country:US
Practice Address - Phone:609-668-0745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-28
Last Update Date:2014-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-14-15075103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst