Provider Demographics
NPI:1063205250
Name:DANTZLER, IYONNA NICOLE
Entity type:Individual
Prefix:
First Name:IYONNA
Middle Name:NICOLE
Last Name:DANTZLER
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 1:623 EASTERN AVE SE APT 417
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5580
Mailing Address - Country:US
Mailing Address - Phone:313-791-4772
Mailing Address - Fax:
Practice Address - Street 1:29226 ORCHARD LAKE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2984
Practice Address - Country:US
Practice Address - Phone:248-450-5853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-28
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty