1922180025 NPI number — MRS. LISELOTTE ANNEMARIE DIXON MFT

Table of content: MRS. LISELOTTE ANNEMARIE DIXON MFT (NPI 1922180025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922180025 NPI number — MRS. LISELOTTE ANNEMARIE DIXON MFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIXON
Provider First Name:
LISELOTTE
Provider Middle Name:
ANNEMARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIXON
Provider Other First Name:
LILO
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922180025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 BEL MARIN KEYS BLVD C5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-883-7652
Provider Business Mailing Address Fax Number:
415-897-8160

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 BEL MARIN KEYS BLVD C5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-883-7652
Provider Business Practice Location Address Fax Number:
415-897-8160
Provider Enumeration Date:
10/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  19998 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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