Provider Demographics
NPI:1235413121
Name:MIXON, DENEQUA DIANE (BS, SST)
Entity type:Individual
Prefix:MS
First Name:DENEQUA
Middle Name:DIANE
Last Name:MIXON
Suffix:
Gender:F
Credentials:BS, SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15001 KERCHEVAL AVENUE
Mailing Address - Street 2:#397
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230
Mailing Address - Country:US
Mailing Address - Phone:586-229-4024
Mailing Address - Fax:
Practice Address - Street 1:707 W. MILWAUKEE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-833-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086335104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker