Provider Demographics
NPI:1104266287
Name:DIXON, TYRA (LCASA)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:DIXON
Suffix:
Gender:F
Credentials:LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 DANIEL PLACE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4817
Mailing Address - Country:US
Mailing Address - Phone:773-716-8404
Mailing Address - Fax:704-612-8213
Practice Address - Street 1:1927 J N PEASE PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4553
Practice Address - Country:US
Practice Address - Phone:704-247-7742
Practice Address - Fax:704-548-9529
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3351-A101YA0400X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health