Healthcare Provider Details

I. General information

NPI: 1114767977
Provider Name (Legal Business Name): DALYNNGIA FUQUA LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40315 MICHIGAN AVE
CANTON MI
48188-2908
US

IV. Provider business mailing address

1258 BERKSHIRE ST
WESTLAND MI
48186-5369
US

V. Phone/Fax

Practice location:
  • Phone: 313-363-1696
  • Fax: 734-544-1084
Mailing address:
  • Phone: 734-882-0858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSC0000001155536
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451023585
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: