MEDICARE: DR. AISHA DIXON-PETERS PSY.D.

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	103TC0700X	Clinical Psychologist	PSY22768	CA

General Provider Information

NPI Number	:	1164505210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AISHA DIXON-PETERS PSY.D.

Provider Business Mailing Address
First Line	:	PO BOX 41533
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-0533
Country	:	US
Telephone Number	:	818-813-2843
Fax Number	:

Provider Business Practice Location Address
First Line	:	4405 W RIVERSIDE DR STE 208
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4050
Country	:	US
Telephone Number	:	818-813-2843
Fax Number	:

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

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	09/19/2012

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