MEDICARE: MRS. LISA GAIL DIXON SUDP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CP60923722	WA

General Provider Information

NPI Number	:	1053947507
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA GAIL DIXON SUDP

Provider Business Mailing Address
First Line	:	8444 N 90TH ST STE 100
Second Line	:
City	:	SCOTTSDALE
State	:	AZ
Zip	:	85258-4437
Country	:	US
Telephone Number	:	602-248-8886
Fax Number	:	602-854-0504

Provider Business Practice Location Address
First Line	:	795 SUNSET BLVD STE F
Second Line	:
City	:	KALISPELL
State	:	MT
Zip	:	59901-3699
Country	:	US
Telephone Number	:	406-206-3885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2020
Last Update Date	:	03/06/2026

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