Provider Demographics
NPI:1912100710
Name:DIXON-STANDARD, MARY KATHERINE (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHERINE
Last Name:DIXON-STANDARD
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888
Mailing Address - Country:US
Mailing Address - Phone:401-781-2700
Mailing Address - Fax:401-781-2790
Practice Address - Street 1:2020 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-2404
Practice Address - Country:US
Practice Address - Phone:401-781-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW01404101YA0400X
RIISW01464101YM0800X, 101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4201380Medicaid