Basic Information
| Provider Information | |||||||||
| NPI: | 1790780583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIXON | ||||||||
| FirstName: | LESLIE | ||||||||
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| Credential: | MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N KEEL RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161483440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004718592 | ||||||||
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| Practice Location | |||||||||
| Address1: | 102 N KEEL RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | HERMITAGE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 161483440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004718592 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 02/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AT-001085-L | PA | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 0746376 | 05 | OH | MEDICAID | 0018232190001 | 05 | PA | MEDICAID |