Provider Demographics
NPI:1588959951
Name:WOMACK, YALANDRIA DETRICA (CLINICAL THERAPIST)
Entity type:Individual
Prefix:
First Name:YALANDRIA
Middle Name:DETRICA
Last Name:WOMACK
Suffix:
Gender:F
Credentials:CLINICAL THERAPIST
Other - Prefix:MRS
Other - First Name:YALANDRIA
Other - Middle Name:DETRICA
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2939 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4825
Mailing Address - Country:US
Mailing Address - Phone:313-396-5300
Mailing Address - Fax:313-396-5353
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI630101491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical