Provider Demographics
NPI:1750725834
Name:DIXON, MARIE ANTOINETTE (LCSW)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:ANTOINETTE
Last Name:DIXON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1535 ESTES DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-4236
Mailing Address - Country:US
Mailing Address - Phone:314-736-0873
Mailing Address - Fax:
Practice Address - Street 1:737 DUNN RD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-1740
Practice Address - Country:US
Practice Address - Phone:314-736-0873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120345821041C0700X
MO20170371981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490063669Medicaid