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General NPI Number Information
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NPI Number | 1295417475
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Entity Type | Individual
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Provider Name | TRISTEN JOHN JORAH LLMSW
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Gender | Male
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Dates
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Enumeration Date | 08/07/2023
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 3260 COOLIDGE HWY
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City | BERKLEY
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State | MI
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Zip | 48072-1694
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Country | US
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Telephone | 248-290-3180
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Fax |
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Provider Business Mailing Address
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Address Line | 1130 N CAMPBELL RD APT 114
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City | ROYAL OAK
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State | MI
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Zip | 48067-1538
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Country | US
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Telephone | 586-321-5733
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6851116932
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License Number State | MI
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