Healthcare Provider Details

I. General information

NPI: 1184171498
Provider Name (Legal Business Name): TMCM4 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 WOODLAND PASS STE 216
EAST LANSING MI
48823-2060
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-347-6944
  • Fax: 517-347-6912
Mailing address:
  • Phone: 517-676-9788
  • Fax: 866-776-7556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801059540
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. MARY BETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788