Provider Demographics
NPI:1124351200
Name:EDWARDS, SANYANI D (TLLP)
Entity type:Individual
Prefix:
First Name:SANYANI
Middle Name:D
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44446
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48244-0446
Mailing Address - Country:US
Mailing Address - Phone:313-215-0545
Mailing Address - Fax:
Practice Address - Street 1:25438 SAINT JAMES
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-1247
Practice Address - Country:US
Practice Address - Phone:313-215-0545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014230103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist