=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235413121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENEQUA DIANE MIXON MS, TLLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2011
-----------------------------------------------------
Last Update Date | 12/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 W. MILWAUKEE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-833-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15001 KERCHEVAL AVE # 397
-----------------------------------------------------
City | GROSSE POINTE PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48230-1361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-229-4024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1235413121
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 6362009487
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------