Provider Demographics
NPI:1053947507
Name:DIXON, LISA GAIL (SUDP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GAIL
Last Name:DIXON
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:GAIL
Other - Last Name:AVELAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SUDP
Mailing Address - Street 1:12600 4TH AVE W APT 5H
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-6430
Mailing Address - Country:US
Mailing Address - Phone:206-419-3883
Mailing Address - Fax:
Practice Address - Street 1:8514 W GAGE BLVD STE G
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-8108
Practice Address - Country:US
Practice Address - Phone:509-222-1275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60923722101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty