Provider Demographics
NPI:1619313947
Name:IVORY, MYLAH TERESE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MYLAH
Middle Name:TERESE
Last Name:IVORY
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 WHITTAKER RD STE 164
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8238
Mailing Address - Country:US
Mailing Address - Phone:734-612-7991
Mailing Address - Fax:
Practice Address - Street 1:2080 WHITTAKER RD STE 164
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8238
Practice Address - Country:US
Practice Address - Phone:734-612-7991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010650111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical