MEDICARE: BRETT STEPHEN DIXON

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

General Provider Information

NPI Number	:	1679099105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRETT STEPHEN DIXON

Provider Business Mailing Address
First Line	:	1410 COLUMBIA RD APT 16K
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-4018
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 COLUMBIA RD APT 16K
Second Line	:
City	:	SOUTH BOSTON
State	:	MA
Zip	:	02127-4018
Country	:	US
Telephone Number	:	774-266-6089
Fax Number	:

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

Provider Enumeration Date	:	08/16/2017
Last Update Date	:	08/16/2017

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