MEDICARE: MS. DETRA DIXON

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	171M00000X	Case Manager/Care Coordinator
2	374J00000X	Doula

General Provider Information

NPI Number	:	1225841083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DETRA DIXON

Provider Business Mailing Address
First Line	:	2557 W MCNICHOLS RD UNIT 23-205
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-3341
Country	:	US
Telephone Number	:	313-444-3179
Fax Number	:

Provider Business Practice Location Address
First Line	:	2557 W MCNICHOLS RD UNIT 23-205
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-3341
Country	:	US
Telephone Number	:	313-444-3179
Fax Number	:

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

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	03/20/2025

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