MEDICARE: THERESA WINDHAM LMSW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1134769276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THERESA WINDHAM LMSW LLC

Provider Business Mailing Address
First Line	:	PO BOX 10
Second Line	:
City	:	MASON
State	:	MI
Zip	:	48854-0010
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2532 SPRING ARBOR RD STE D
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49203-3663
Country	:	US
Telephone Number	:	517-798-5555
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING
Name	:	MARYBETH HOUPT
Credential	:
Telephone Number	:	517-676-9797

Provider Enumeration Date	:	01/07/2020
Last Update Date	:	05/28/2026

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