Provider Demographics
NPI:1033536321
Name:ALLIX, MARY (DBH, MA, LLPC, CAADC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:ALLIX
Suffix:
Gender:F
Credentials:DBH, MA, LLPC, CAADC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:CRUDUP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19502 MARK TWAIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1915
Mailing Address - Country:US
Mailing Address - Phone:313-703-6663
Mailing Address - Fax:313-397-9465
Practice Address - Street 1:707 WEST MILWAUKEE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401007949101YM0800X
261QM0850X, 261QP2300X
MIC-02275101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care