Provider Demographics
NPI:1871705095
Name:DIXON, SYLVIA MIRANDA (PT)
Entity type:Individual
Prefix:MS
First Name:SYLVIA
Middle Name:MIRANDA
Last Name:DIXON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:S
Other - Last Name:DIXON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:251 MEDICAL PLAZA LANE
Mailing Address - Street 2:SUITE D
Mailing Address - City:WHITESBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41858
Mailing Address - Country:US
Mailing Address - Phone:606-632-1188
Mailing Address - Fax:606-632-0075
Practice Address - Street 1:251 MEDICAL PLAZA LN
Practice Address - Street 2:SUITE D
Practice Address - City:WHITESBURG
Practice Address - State:KY
Practice Address - Zip Code:41858-9323
Practice Address - Country:US
Practice Address - Phone:606-632-1188
Practice Address - Fax:606-632-0075
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004691225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1700075314OtherNPI GROUP
0667505Medicare PIN