Provider Demographics
NPI:1366734048
Name:MACON-DICKERSON, VENUS (CADC-M)
Entity type:Individual
Prefix:
First Name:VENUS
Middle Name:
Last Name:MACON-DICKERSON
Suffix:
Gender:F
Credentials:CADC-M
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13575 LESURE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3131
Mailing Address - Country:US
Mailing Address - Phone:313-493-4410
Mailing Address - Fax:313-493-4415
Practice Address - Street 1:13575 LESURE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3131
Practice Address - Country:US
Practice Address - Phone:313-493-4410
Practice Address - Fax:313-493-4415
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-04821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)