Provider Demographics
NPI:1497186050
Name:BENTON-BROWN, MIAYANA
Entity Type:Individual
Prefix:
First Name:MIAYANA
Middle Name:
Last Name:BENTON-BROWN
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 1:555 TOWNER ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-3000
Mailing Address - Fax:
Practice Address - Street 1:4075 PACKARD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1548
Practice Address - Country:US
Practice Address - Phone:734-477-5661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801094829104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker