Provider Demographics
NPI:1417225954
Name:TRIPP, LAKECHA MARHONDA
Entity Type:Individual
Prefix:MRS
First Name:LAKECHA
Middle Name:MARHONDA
Last Name:TRIPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28467 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9763
Mailing Address - Country:US
Mailing Address - Phone:248-914-4169
Mailing Address - Fax:
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:734-324-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MITRIPPLAMedicaid