Healthcare Provider Details

I. General information

NPI: 1386267706
Provider Name (Legal Business Name): THE ADAM DIXON PERSEVERANCE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 N 19TH AVE # 300-14
PHOENIX AZ
85015-3210
US

IV. Provider business mailing address

5060 N 19TH AVE # 300-14
PHOENIX AZ
85015-3210
US

V. Phone/Fax

Practice location:
  • Phone: 480-560-6370
  • Fax:
Mailing address:
  • Phone: 480-560-6370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ADAM CONLEY DIXON
Title or Position: CEO
Credential:
Phone: 480-560-6370