Provider Demographics
NPI:1295291292
Name:DIXON, OLIVIA VIVIA
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:VIVIA
Last Name:DIXON
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 1:410 EAST MACPHAIL RD
Mailing Address - Street 2:
Mailing Address - City:BELAIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 E MACPHAIL RD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4410
Practice Address - Country:US
Practice Address - Phone:410-879-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
201420927Other201420927