Basic Information
| Provider Information | |||||||||
| NPI: | 1730385170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YALLAH | ||||||||
| FirstName: | DEMPSTER | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 929 SHERBOURNE ST | ||||||||
| Address2: | |||||||||
| City: | INKSTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481411381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135610670 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9315 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134504500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2007 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | 6802073612 | MI | N | Behavioral Health & Social Service Providers | Social Worker | School | 104100000X | 6802073612 | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6802073612 | 01 | MI | SOCIAL WORKER | OTHER |