Healthcare Provider Details

I. General information

NPI: 1912100710
Provider Name (Legal Business Name): MARY KATHERINE DIXON-STANDARD MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2007
Last Update Date: 11/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 ELMWOOD AVE
WARWICK RI
02888-2404
US

IV. Provider business mailing address

2020 ELMWOOD AVE
WARWICK RI
02888
US

V. Phone/Fax

Practice location:
  • Phone: 401-781-2700
  • Fax:
Mailing address:
  • Phone: 401-781-2700
  • Fax: 401-781-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberISW01404
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberISW01464
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberISW01464
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberISW01464
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: