MEDICARE: HALLE GRACE DETRIXHE

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	103TC1900X	Counseling Psychologist
3	1041C0700X	Clinical Social Worker
4	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1053162545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HALLE GRACE DETRIXHE

Provider Business Mailing Address
First Line	:	2929 WYCLIFF AVE APT 2311
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-6652
Country	:	US
Telephone Number	:	310-213-7574
Fax Number	:

Provider Business Practice Location Address
First Line	:	2929 WYCLIFF AVE APT 2311
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-6652
Country	:	US
Telephone Number	:	310-213-7574
Fax Number	:

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

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/01/2024

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Directions to “ HALLE GRACE DETRIXHE ” Practice Location

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