Provider Demographics
NPI:1083495741
Name:YRELUS, MACKENSON
Entity Type:Individual
Prefix:
First Name:MACKENSON
Middle Name:
Last Name:YRELUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 TRIANA BLVD SW APT 119
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-5444
Mailing Address - Country:US
Mailing Address - Phone:239-462-0305
Mailing Address - Fax:
Practice Address - Street 1:4110 TRIANA BLVD SW APT 119
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-5444
Practice Address - Country:US
Practice Address - Phone:239-462-0305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool