MEDICARE: DIXIE LEE GRACE PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	LP1772	MN
2	103TC0700X	Clinical Psychologist	LP1772	MN

General Provider Information

NPI Number	:	1932191889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIXIE LEE GRACE PH.D.

Provider Business Mailing Address
First Line	:	1313 5TH ST SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4511
Country	:	US
Telephone Number	:	612-379-1205
Fax Number	:	612-379-3183

Provider Business Practice Location Address
First Line	:	1313 5TH ST SE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4504
Country	:	US
Telephone Number	:	612-379-1205
Fax Number	:	612-379-3183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2005
Last Update Date	:	09/11/2025

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