Provider Demographics
NPI:1861809345
Name:DILLARD, ALICS
Entity type:Individual
Prefix:
First Name:ALICS
Middle Name:
Last Name:DILLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4250 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1818
Mailing Address - Country:US
Mailing Address - Phone:313-833-8100
Mailing Address - Fax:
Practice Address - Street 1:4250 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1818
Practice Address - Country:US
Practice Address - Phone:313-833-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014291101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health