Provider Demographics
NPI:1841803780
Name:DENILSON IKENWUDE, ALISA REBECCA (LPC)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:REBECCA
Last Name:DENILSON IKENWUDE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ALISA
Other - Middle Name:REBECCA
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:29155 NORTHWESTERN HWY #652
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:284-890-5807
Mailing Address - Fax:
Practice Address - Street 1:AL THANYA STREET 685, BUILDING 163, ZONE 54, FLAT 6
Practice Address - Street 2:
Practice Address - City:MEHAIRJA
Practice Address - State:DOHA
Practice Address - Zip Code:00000
Practice Address - Country:QA
Practice Address - Phone:974-316-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-30
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012289101YP2500X
MI6401222447101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional