Provider Demographics
NPI:1023825254
Name:TEAGUE, MAKALYNN JAMYIAH
Entity type:Individual
Prefix:
First Name:MAKALYNN
Middle Name:JAMYIAH
Last Name:TEAGUE
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 1:2995 E GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3133
Mailing Address - Country:US
Mailing Address - Phone:313-758-0150
Mailing Address - Fax:
Practice Address - Street 1:2995 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3133
Practice Address - Country:US
Practice Address - Phone:313-758-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist