Provider Demographics
NPI:1447084546
Name:DIXON, MATTHEW JOSEPH
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
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 1:12000 129TH LN NE APT P203
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-8639
Mailing Address - Country:US
Mailing Address - Phone:616-690-0422
Mailing Address - Fax:
Practice Address - Street 1:3000 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-5371
Practice Address - Country:US
Practice Address - Phone:254-402-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABACB1143922106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician