Provider Demographics
NPI:1922647932
Name:DIXON-WILSON, SHERDENA
Entity Type:Individual
Prefix:
First Name:SHERDENA
Middle Name:
Last Name:DIXON-WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 KIRK RD
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2209
Mailing Address - Country:US
Mailing Address - Phone:330-398-8625
Mailing Address - Fax:
Practice Address - Street 1:165 E PARK AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-2352
Practice Address - Country:US
Practice Address - Phone:330-544-8005
Practice Address - Fax:330-544-9379
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 101YA0400X, 171M00000X, 171M00000X
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000246668Medicaid