Provider Demographics
NPI:1356913206
Name:DIXON, SHANE G
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:G
Last Name:DIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 LAKE HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-1737
Mailing Address - Country:US
Mailing Address - Phone:407-732-1290
Mailing Address - Fax:
Practice Address - Street 1:6400 LAKE HORSESHOE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818-1737
Practice Address - Country:US
Practice Address - Phone:407-732-1290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist