Provider Demographics
NPI:1770994709
Name:DIXON, LAURA (ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATC
Mailing Address - Street 1:1172 SARANAP AVE APT 7B
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1133
Mailing Address - Country:US
Mailing Address - Phone:510-367-9547
Mailing Address - Fax:
Practice Address - Street 1:2227 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2325
Practice Address - Country:US
Practice Address - Phone:510-642-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
90002101OtherBOC CERTIFICATION