Healthcare Provider Details

I. General information

NPI: 1710229562
Provider Name (Legal Business Name): DATARA MICHENER LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA MICHENER LLPC

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 03/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W UNIVERSITY DR
ROCHESTER MI
48307-1845
US

IV. Provider business mailing address

PO BOX 530432
LIVONIA MI
48153-0432
US

V. Phone/Fax

Practice location:
  • Phone: 248-601-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401013542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: