Provider Demographics
NPI:1386154425
Name:DIXON, STEPHANIE O (PHD, MSCP, LMHC)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:O
Last Name:DIXON
Suffix:
Gender:F
Credentials:PHD, MSCP, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2744
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-0744
Mailing Address - Country:US
Mailing Address - Phone:808-285-6230
Mailing Address - Fax:
Practice Address - Street 1:2176 LAUWILIWILI ST STE 44
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-1881
Practice Address - Country:US
Practice Address - Phone:808-285-6230
Practice Address - Fax:888-233-3453
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-03
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMHC-464101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI818966Medicaid