Provider Demographics
NPI:1528691680
Name:DIX, MICHELLE LYNN (CHW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:DIX
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4937
Practice Address - Street 1:3425 13TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1340
Practice Address - Country:US
Practice Address - Phone:541-523-7400
Practice Address - Fax:541-523-4937
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22-QMHA-I-003286171M00000X
ORTHW0047172V00000X
ORTHW000000007172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR4276768OtherDRIVERS LICENSE
OR500776546Medicaid
OR500813182Medicaid