Healthcare Provider Details

I. General information

NPI: 1093265746
Provider Name (Legal Business Name): TAJWANA BURRELL CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

V. Phone/Fax

Practice location:
  • Phone: 313-832-3100
  • Fax: 313-832-0018
Mailing address:
  • Phone: 313-832-3100
  • Fax: 313-832-0018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: