Healthcare Provider Details

I. General information

NPI: 1154109437
Provider Name (Legal Business Name): ELISE KRISTINE DIXON M.S. CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 09/19/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14651 DALLAS PKWY STE 200
DALLAS TX
75254-8856
US

IV. Provider business mailing address

525 SE 38TH AVE
PORTLAND OR
97214-3201
US

V. Phone/Fax

Practice location:
  • Phone: 214-575-2999
  • Fax:
Mailing address:
  • Phone: 503-724-7815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number17232
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: