Provider Demographics
NPI:1134108194
Name:DIX, C. VINCENT (PHD)
Entity type:Individual
Prefix:
First Name:C. VINCENT
Middle Name:
Last Name:DIX
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2880 CAPITAL MEDICAL BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4671
Mailing Address - Country:US
Mailing Address - Phone:850-878-1142
Mailing Address - Fax:850-222-1194
Practice Address - Street 1:2880 CAPITAL MEDICAL BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4671
Practice Address - Country:US
Practice Address - Phone:850-878-1142
Practice Address - Fax:850-222-1194
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY002151103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75943OtherBLUE CROSS/BLUE SHIELD #
FL75943OtherBLUE CROSS/BLUE SHIELD #