Provider Demographics
NPI:1902221054
Name:DIXON, MARY HEATHER
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HEATHER
Last Name:DIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:HEATHER
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1107 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35010-3919
Mailing Address - Country:US
Mailing Address - Phone:256-279-5869
Mailing Address - Fax:
Practice Address - Street 1:1107 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3919
Practice Address - Country:US
Practice Address - Phone:256-279-5869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3256101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL229248Medicaid