Healthcare Provider Details

I. General information

NPI: 1386905461
Provider Name (Legal Business Name): AMANDA LEE DIXON LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 06/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LAUREL AVE
CORNWALL NY
12518-1469
US

IV. Provider business mailing address

495 STANTON TER
POUGHKEEPSIE NY
12603-1164
US

V. Phone/Fax

Practice location:
  • Phone: 845-235-2267
  • Fax:
Mailing address:
  • Phone: 845-235-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005162
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: