Provider Demographics
NPI:1952799389
Name:DIXON, THADDEUS (CACP)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:CACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 GREGG HWY
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6341
Mailing Address - Country:US
Mailing Address - Phone:803-649-1900
Mailing Address - Fax:803-643-2926
Practice Address - Street 1:1105 GREGG HWY
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6341
Practice Address - Country:US
Practice Address - Phone:803-649-1900
Practice Address - Fax:803-643-2926
Is Sole Proprietor?:No
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101Y00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAD01AKMedicaid