Provider Demographics
NPI:1255771713
Name:WIXON, HOLLY GENE
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:GENE
Last Name:WIXON
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 1:8131 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2610
Mailing Address - Country:US
Mailing Address - Phone:616-350-7781
Mailing Address - Fax:
Practice Address - Street 1:128 S COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1510
Practice Address - Country:US
Practice Address - Phone:517-325-9090
Practice Address - Fax:517-325-9091
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801095663104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker