Provider Demographics
NPI:1457394983
Name:DIXON, DENISE (PHD)
Entity type:Individual
Prefix:DR
First Name:DENISE
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 RUSTIC RD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2033
Mailing Address - Country:US
Mailing Address - Phone:631-456-9426
Mailing Address - Fax:
Practice Address - Street 1:646 MAIN ST
Practice Address - Street 2:2ND FLOOR, SUITE 203
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2235
Practice Address - Country:US
Practice Address - Phone:631-456-9426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015481103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVN2811OtherMEDICARE
NY02794076Medicaid