Provider Demographics
NPI:1659122588
Name:IVERSON, DETRA
Entity Type:Individual
Prefix:
First Name:DETRA
Middle Name:
Last Name:IVERSON
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 1:6726 IOWA STREET
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:TURTLE ISLAND
Mailing Address - Zip Code:48212
Mailing Address - Country:IM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4431 ASHLAND STREET
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:TURTLE ISLAND
Practice Address - Zip Code:48215
Practice Address - Country:IM
Practice Address - Phone:313-685-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
102X00000X, 172A00000X, 372500000X, 374K00000X, 390200000X, 374U00000X
MI374J00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No374J00000XNursing Service Related ProvidersDoula
No374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner
No376J00000XNursing Service Related ProvidersHomemaker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program