Healthcare Provider Details

I. General information

NPI: 1043002470
Provider Name (Legal Business Name): DEZRICK OMONT DIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 NORTH DUKE ST SUITE 1 #1193
DURHAM NC
27704-8032
US

IV. Provider business mailing address

3600 NORTH DUKE ST SUITE 1 #1193
DURHAM NC
27704-8032
US

V. Phone/Fax

Practice location:
  • Phone: 919-443-5358
  • Fax:
Mailing address:
  • Phone: 919-443-5358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2025-13014-01
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: