Basic Information
Provider Information | |||||||||
NPI: | 1356473557 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AKINFENWA | ||||||||
FirstName: | ANNE | ||||||||
MiddleName: | O | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA ,TLLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 555 TOWNER ST | ||||||||
Address2: | PO BOX 915 | ||||||||
City: | YPSILANTI | ||||||||
State: | MI | ||||||||
PostalCode: | 481985752 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7345443000 | ||||||||
FaxNumber: | 7345446732 | ||||||||
Practice Location | |||||||||
Address1: | 2140 E ELLSWORTH RD | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481082552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7342223563 | ||||||||
FaxNumber: | 7342223461 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401008713 | MI | X |   | Behavioral Health & Social Service Providers | Counselor | Professional | 103TS0200X | 6301012448 | MI | X |   | Behavioral Health & Social Service Providers | Psychologist | School |
No ID Information.