Provider Demographics
NPI:1720738115
Name:DIXON, KAREN DIONNE
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:DIONNE
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 1:3715 MEADOW GREEN DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-9482
Mailing Address - Country:US
Mailing Address - Phone:352-874-0974
Mailing Address - Fax:
Practice Address - Street 1:3715 MEADOW GREEN DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-9482
Practice Address - Country:US
Practice Address - Phone:352-874-0974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020141400Medicaid