Provider Demographics
NPI:1639695646
Name:DEXTER, MARYANN
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:DEXTER
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 1:542 E SEBEWAING ST APT 1
Mailing Address - Street 2:
Mailing Address - City:SEBEWAING
Mailing Address - State:MI
Mailing Address - Zip Code:48759-1135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1375 R DALE WERTZ DR
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1365
Practice Address - Country:US
Practice Address - Phone:989-269-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No172V00000XOther Service ProvidersCommunity Health Worker