Provider Demographics
NPI:1295124337
Name:DIX, NANNETTE BERTRAM (CSW)
Entity type:Individual
Prefix:
First Name:NANNETTE
Middle Name:BERTRAM
Last Name:DIX
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 S SHELBY ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1107
Mailing Address - Country:US
Mailing Address - Phone:502-635-4518
Mailing Address - Fax:502-636-0597
Practice Address - Street 1:1436 S SHELBY ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1107
Practice Address - Country:US
Practice Address - Phone:502-635-4518
Practice Address - Fax:502-636-0597
Is Sole Proprietor?:No
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYCSW 67241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical