Healthcare Provider Details

I. General information

NPI: 1154254787
Provider Name (Legal Business Name): YODIT WOLDEGABREL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 REO RD
LANSING MI
48910
US

IV. Provider business mailing address

2107 REO RD.
LANSING MI
51721-4298
US

V. Phone/Fax

Practice location:
  • Phone: 517-214-2986
  • Fax:
Mailing address:
  • Phone: 517-214-2986
  • Fax: 517-214-2986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAS330419756
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: