Provider Demographics
NPI:1972062321
Name:WYCKOFF, TEMEKIA M
Entity type:Individual
Prefix:MS
First Name:TEMEKIA
Middle Name:M
Last Name:WYCKOFF
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:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0563
Mailing Address - Country:US
Mailing Address - Phone:313-468-0673
Mailing Address - Fax:
Practice Address - Street 1:153 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3517
Practice Address - Country:US
Practice Address - Phone:313-468-0673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI802268787101YM0800X, 103TP2701X, 171M00000X, 251E00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802268787Medicaid