Basic Information
| Provider Information | |||||||||
| NPI: | 1134425929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSYD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DRAHOTA | ||||||||
| OtherFirstName: | TRACY | ||||||||
| OtherMiddleName: | JO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2702 NORTH 3RD STREET | ||||||||
| Address2: | 4020 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850044608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023233407 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 3830 E VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850086936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022437277 | ||||||||
| FaxNumber: | 6022860808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2011 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 4145 | AZ | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | 3289 | OR | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 684311 | 05 | AZ | MEDICAID |