Basic Information
| Provider Information | |||||||||
| NPI: | 1073681961 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | PRISCILLE | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 203 | ||||||||
| Address2: | |||||||||
| City: | NEWFIELD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040560203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077934273 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 50 MOODY ST | ||||||||
| Address2: | |||||||||
| City: | SACO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040721536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004343000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 09/09/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CC2535 | ME | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 431549599 | 05 | ME | MEDICAID |