Healthcare Provider Details

I. General information

NPI: 1134615594
Provider Name (Legal Business Name): TRESSA KENDALL LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRESSA LICKFELT LBSW

II. Dates (important events)

Enumeration Date: 07/09/2018
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 CEDAR LAKE RD
OSCODA MI
48750-9499
US

IV. Provider business mailing address

1199 HARRIS AVENUE PO BOX 310
TAWAS MI
48763-0310
US

V. Phone/Fax

Practice location:
  • Phone: 989-739-1469
  • Fax: 989-739-9901
Mailing address:
  • Phone: 989-362-8636
  • Fax: 989-362-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802084930
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: