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General NPI Number Information
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NPI Number | 1598587966
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Entity Type | Organization
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Legal Business Name | TA THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 10/28/2024
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Last Update Date | 10/28/2024
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Provider Practice Location Address
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Address Line | 10936 OLD STATE RD
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City | JOHANNESBURG
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State | MI
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Zip | 49751
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Country | US
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Telephone | 734-755-3228
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 196
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City | LUZERNE
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State | MI
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Zip | 48636-0196
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TRACI A DORAN
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Credential | LMSW
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Telephone | 734-755-3228
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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 |
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License Number State |
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