Healthcare Provider Details

I. General information

NPI: 1043722283
Provider Name (Legal Business Name): SABRA MARY DIXON LSUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

591 W 800 N
OREM UT
84057-3762
US

IV. Provider business mailing address

3608 N 180 E
PROVO UT
84604-4566
US

V. Phone/Fax

Practice location:
  • Phone: 801-427-9726
  • Fax:
Mailing address:
  • Phone: 801-427-9726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10181747-6005
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: