Provider Demographics
NPI:1265602288
Name:DIX, CAROLE ELYSE (LMSW)
Entity type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:ELYSE
Last Name:DIX
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1916
Mailing Address - Country:US
Mailing Address - Phone:315-676-1555
Mailing Address - Fax:313-576-1570
Practice Address - Street 1:4646 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:315-676-1555
Practice Address - Fax:313-576-1570
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-05
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801034135323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility