Healthcare Provider Details

I. General information

NPI: 1831797349
Provider Name (Legal Business Name): ANGELA M TIEMEYER M.S., TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N CENTER ST
NORTHVILLE MI
48167-1277
US

IV. Provider business mailing address

14558 FAUST AVE
DETROIT MI
48223-2321
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4053
  • Fax:
Mailing address:
  • Phone: 269-598-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009203
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: