Provider Demographics
NPI:1477235240
Name:DIXON, MONTANA
Entity type:Individual
Prefix:
First Name:MONTANA
Middle Name:
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 1:790 E BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-1906
Mailing Address - Country:US
Mailing Address - Phone:626-254-5000
Mailing Address - Fax:
Practice Address - Street 1:790 E BONITA AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1906
Practice Address - Country:US
Practice Address - Phone:626-254-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X, 172V00000X
CAAMFT148495106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No172V00000XOther Service ProvidersCommunity Health Worker