Provider Demographics
NPI:1548514342
Name:DIXON, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:DIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 TAYLOR AVE N APT 103
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-3340
Mailing Address - Country:US
Mailing Address - Phone:206-999-5324
Mailing Address - Fax:
Practice Address - Street 1:7625 PARAGON RD
Practice Address - Street 2:SUITE C
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4067
Practice Address - Country:US
Practice Address - Phone:877-480-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23478225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist