Provider Demographics
NPI:1881176105
Name:YANCY, MARK DIXON SR
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:DIXON
Last Name:YANCY
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5869 MARBLE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-3967
Mailing Address - Country:US
Mailing Address - Phone:248-943-7111
Mailing Address - Fax:
Practice Address - Street 1:5869 MARBLE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-3967
Practice Address - Country:US
Practice Address - Phone:248-943-7111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016811101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional