MEDICARE: TAMARRA YVETTE GLENN BA

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	101YM0800X	Mental Health Counselor	6451024904	MI

General Provider Information

NPI Number	:	1851797112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMARRA YVETTE GLENN BA

Provider Business Mailing Address
First Line	:	20222 ORLEANS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-1356
Country	:	US
Telephone Number	:	313-919-3456
Fax Number	:

Provider Business Practice Location Address
First Line	:	20222 ORLEANS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48203-1356
Country	:	US
Telephone Number	:	313-919-3456
Fax Number	:

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

Provider Enumeration Date	:	11/14/2014
Last Update Date	:	05/05/2026

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