Provider Demographics
NPI:1912629221
Name:DIXON, LATESHA MACHELL (LPC)
Entity Type:Individual
Prefix:MS
First Name:LATESHA
Middle Name:MACHELL
Last Name:DIXON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:664 IVY BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5520
Mailing Address - Country:US
Mailing Address - Phone:478-335-6838
Mailing Address - Fax:
Practice Address - Street 1:664 IVY BROOK WAY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5520
Practice Address - Country:US
Practice Address - Phone:478-335-6838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012971101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional