=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033527338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANTE DEMITRIUS DIXSON PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2014
-----------------------------------------------------
Last Update Date | 08/24/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16250 NORTHLAND DR STE 204
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-5226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-436-1511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3070 WHISPERWOOD DR APT 417
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-3419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-436-1511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6301018389
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------