Healthcare Provider Details

I. General information

NPI: 1750485272
Provider Name (Legal Business Name): TELESHA TEMPLE LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 MILITARY ST
PORT HURON MI
48060-5416
US

IV. Provider business mailing address

19150 TIREMAN ST
DETROIT MI
48228-3334
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-7050
  • Fax: 810-987-2336
Mailing address:
  • Phone: 313-582-3412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6802084652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: