Provider Demographics
NPI:1467702407
Name:NDIAYE, MYA PATRICE
Entity Type:Individual
Prefix:
First Name:MYA
Middle Name:PATRICE
Last Name:NDIAYE
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 1:16320 E 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2440
Mailing Address - Country:US
Mailing Address - Phone:313-414-1945
Mailing Address - Fax:586-944-2731
Practice Address - Street 1:16320 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2440
Practice Address - Country:US
Practice Address - Phone:313-414-1945
Practice Address - Fax:586-944-2731
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015244101YM0800X, 171M00000X
MI1-17-25043103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst