Basic Information
| Provider Information | |||||||||
| NPI: | 1265602288 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIX | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | ELYSE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156761555 | ||||||||
| FaxNumber: | 3135761570 | ||||||||
| Practice Location | |||||||||
| Address1: | 4646 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482011916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3156761555 | ||||||||
| FaxNumber: | 3135761570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2008 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 6801034135 | MI | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
No ID Information.