Basic Information
| Provider Information | |||||||||
| NPI: | 1861893554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | GENAVAE | ||||||||
| MiddleName: | PIERRE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3490 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950504333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082430222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3490 THE ALAMEDA | ||||||||
| Address2: | |||||||||
| City: | SANTA CLARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950504333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4082430222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2014 | ||||||||
| LastUpdateDate: | 06/02/2015 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.