MEDICARE: MARIESA TINKHAM LLMSW

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	1041C0700X	Clinical Social Worker	6801096292	MI

General Provider Information

NPI Number	:	1821429390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIESA TINKHAM LLMSW

Provider Business Mailing Address
First Line	:	1485 S M-139
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023
Country	:	US
Telephone Number	:	269-925-0585
Fax Number	:	269-927-1326

Provider Business Practice Location Address
First Line	:	1485 S M-139
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49023
Country	:	US
Telephone Number	:	269-925-0585
Fax Number	:	269-927-1326

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2013
Last Update Date	:	12/09/2013

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