Healthcare Provider Details

I. General information

NPI: 1780247403
Provider Name (Legal Business Name): RE'ANA DIXON QMHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 MARKET AVE N
CANTON OH
44702-1017
US

IV. Provider business mailing address

5545 SMITH ROAD
BROOK PARK OH
44142
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4553
  • Fax: 330-493-3761
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM2100260
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: