MEDICARE: SAMUEL L DIXON PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	E-0000684	OH

General Provider Information

NPI Number	:	1417176942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL L DIXON PH.D.

Provider Business Mailing Address
First Line	:	6100 CHANNINGWAY BLVD STE 201
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-2910
Country	:	US
Telephone Number	:	614-861-2786
Fax Number	:	614-861-2792

Provider Business Practice Location Address
First Line	:	6100 CHANNINGWAY BLVD STE 201
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-2910
Country	:	US
Telephone Number	:	614-861-2786
Fax Number	:	614-861-2792

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	07/09/2007

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