Basic Information
| Provider Information | |||||||||
| NPI: | 1740562800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YAX | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | V | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866199986 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18 MARKET ST STE C | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480437403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867832222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2011 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089069 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.