Healthcare Provider Details

I. General information

NPI: 1710147186
Provider Name (Legal Business Name): YVONNE LYNN BOSTIC LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

36500 W 9 MILE RD
FARMINGTON HILLS MI
48335-3806
US

V. Phone/Fax

Practice location:
  • Phone: 313-344-9909
  • Fax:
Mailing address:
  • Phone: 248-416-9866
  • Fax: 248-416-9866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010525
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: