Healthcare Provider Details

I. General information

NPI: 1619204146
Provider Name (Legal Business Name): STEPHANIE ORLENA DIXON LCSW, LCAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 S MATTIS AVE
CHAMPAIGN IL
61821-5923
US

IV. Provider business mailing address

611 W PARK ST
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-2855
  • Fax: 217-365-2856
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149024669
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-25972
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC013323
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: