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General NPI Number Information
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NPI Number | 1336648179
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Entity Type | Individual
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Provider Name | TAMARA LYNN HALLIBURTON
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Gender | Female
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Dates
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Enumeration Date | 02/07/2018
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Last Update Date | 02/28/2023
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Provider Practice Location Address
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Address Line | 23077 GREENFIELD RD STE 455
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City | SOUTHFIELD
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State | MI
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Zip | 48075-3740
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Country | US
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Telephone | 313-683-2753
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Fax |
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Provider Business Mailing Address
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Address Line | 23077 GREENFIELD RD SUITE 455 PMB 1063
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City | SOUTHFIELD
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State | MI
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Zip | 48075-3740
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Country | US
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Telephone | 313-683-2753
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6401016351
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License Number State | MI
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