Provider Demographics
NPI:1114767977
Name:FUQUA, DALYNNGIA (LLPC)
Entity type:Individual
Prefix:
First Name:DALYNNGIA
Middle Name:
Last Name:FUQUA
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1258 BERKSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5369
Mailing Address - Country:US
Mailing Address - Phone:734-882-0858
Mailing Address - Fax:
Practice Address - Street 1:40315 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2908
Practice Address - Country:US
Practice Address - Phone:313-363-1696
Practice Address - Fax:734-544-1084
Is Sole Proprietor?:No
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISC0000001155536101YS0200X
MI6451023585101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool