=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346305075
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ANGEL DIXON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1745 ENTERPRISE DR BLDG 2 SUITE I-64
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94533-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-427-6640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1017 B-CAPITAL STREET
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-315-8324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | RW0949
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------