Healthcare Provider Details

I. General information

NPI: 1851590293
Provider Name (Legal Business Name): MS. TARA MARIE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W US 2 GOGEBIC COUNTY COMMUNITY MENTAL HEALTH
WAKEFIELD MI
49968-9539
US

IV. Provider business mailing address

103 W US HIGHWAY 2
WAKEFIELD MI
49968-9515
US

V. Phone/Fax

Practice location:
  • Phone: 906-229-6120
  • Fax:
Mailing address:
  • Phone: 906-229-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number127350-121
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801089456
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: