=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316042088
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERAPEUTIC ALLIANCE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2006
-----------------------------------------------------
Last Update Date | 03/12/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25 N. NORTH SHORE DRIVE
-----------------------------------------------------
City | LAKE ORION
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48362-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-628-8908
-----------------------------------------------------
Fax | 248-693-5247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 N AXFORD ST UNIT 53
-----------------------------------------------------
City | LAKE ORION
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48361-8102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-628-8908
-----------------------------------------------------
Fax | 248-693-5247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MS. WENDY SHARPE TAGGART
-----------------------------------------------------
Credential | LMSW, ACSW, ACCHT
-----------------------------------------------------
Telephone | 248-628-8908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801065246
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------