Healthcare Provider Details

I. General information

NPI: 1972062321
Provider Name (Legal Business Name): MS. TEMEKIA M WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 03/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 CALIFORNIA ST
HIGHLAND PARK MI
48203-3517
US

IV. Provider business mailing address

PO BOX 563
SOUTHFIELD MI
48037-0563
US

V. Phone/Fax

Practice location:
  • Phone: 313-468-0673
  • Fax:
Mailing address:
  • Phone: 313-468-0673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number802268787
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number802268787
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number802268787
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number802268787
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number802268787
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: