Healthcare Provider Details

I. General information

NPI: 1699197905
Provider Name (Legal Business Name): VICKI LEE YAZZIE BA, LBSW, QMHP,QMRP,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2014
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S CRAPO ST SUITE 200
MOUNT PLEASANT MI
48858-2941
US

IV. Provider business mailing address

301 S CRAPO ST SUITE 200
MOUNT PLEASANT MI
48858-2941
US

V. Phone/Fax

Practice location:
  • Phone: 989-772-5938
  • Fax: 989-775-7701
Mailing address:
  • Phone: 989-772-5938
  • Fax: 989-775-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802071563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: