Provider Demographics
NPI:1710719844
Name:EVWARAYE, FEJIRO
Entity type:Individual
Prefix:
First Name:FEJIRO
Middle Name:
Last Name:EVWARAYE
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 1:7414 KIPLING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48206-2679
Mailing Address - Country:US
Mailing Address - Phone:810-445-8382
Mailing Address - Fax:
Practice Address - Street 1:1760 S TELEGRAPH RD STE 103&240
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0180
Practice Address - Country:US
Practice Address - Phone:248-256-5209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MI6362010029101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist