Healthcare Provider Details

I. General information

NPI: 1841884053
Provider Name (Legal Business Name): DANIEL WALLACE ENYIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2021
Last Update Date: 02/28/2021
Certification Date: 02/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31465 HARLO DR APT E
MADISON HEIGHTS MI
48071-1987
US

IV. Provider business mailing address

16320 E 9 MILE RD
EASTPOINTE MI
48021-2440
US

V. Phone/Fax

Practice location:
  • Phone: 248-505-4649
  • Fax:
Mailing address:
  • Phone: 586-218-8570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: