Provider Demographics
NPI:1932645405
Name:DODSON, DIANE LOUISE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:LOUISE
Last Name:DODSON
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 1:5500 TRUMBULL ST APT 315
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1746
Mailing Address - Country:US
Mailing Address - Phone:313-286-4661
Mailing Address - Fax:
Practice Address - Street 1:5500 TRUMBULL APT 315
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208
Practice Address - Country:US
Practice Address - Phone:313-822-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)