Basic Information
| Provider Information | |||||||||
| NPI: | 1417225954 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TRIPP | ||||||||
| FirstName: | LAKECHA | ||||||||
| MiddleName: | MARHONDA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28467 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | FLAT ROCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481349763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489144169 | ||||||||
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| Practice Location | |||||||||
| Address1: | 14799 DIX TOLEDO RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343248326 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2011 | ||||||||
| LastUpdateDate: | 04/16/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | TRIPPLA | 05 | MI | MEDICAID |