Healthcare Provider Details

I. General information

NPI: 1164047577
Provider Name (Legal Business Name): ALEXANDRIA YANNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19275 NORTHLINE RD
SOUTHGATE MI
48195-2220
US

IV. Provider business mailing address

26510 WILLOW CV
WOODHAVEN MI
48183-4457
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7716
  • Fax:
Mailing address:
  • Phone: 734-892-4999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: