Healthcare Provider Details

I. General information

NPI: 1619953916
Provider Name (Legal Business Name): DAVID V DIXON LCPC LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 KIMBERLY RD SUITE 7B
TWIN FALLS ID
83301-7881
US

IV. Provider business mailing address

1300 KIMBERLY RD SUITE 7B
TWIN FALLS ID
83301-7881
US

V. Phone/Fax

Practice location:
  • Phone: 208-736-1636
  • Fax: 208-735-1656
Mailing address:
  • Phone: 208-736-1636
  • Fax: 208-735-1656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCPC2990
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMFT2991
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: