Provider Demographics
NPI:1568018208
Name:WILLOUGHBY, DEZHA
Entity Type:Individual
Prefix:
First Name:DEZHA
Middle Name:
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26789 WOODWARD AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1334
Mailing Address - Country:US
Mailing Address - Phone:248-631-4728
Mailing Address - Fax:
Practice Address - Street 1:229 N SHELDON RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1524
Practice Address - Country:US
Practice Address - Phone:313-278-4601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI7501014617225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician