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General NPI Number Information
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NPI Number | 1760933121
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Entity Type | Individual
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Provider Name | TARA FLEIS LLPC
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Gender | Female
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Dates
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Enumeration Date | 10/20/2016
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Last Update Date | 10/20/2016
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Provider Practice Location Address
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Address Line | 9885 STATE HIGHWAY M95
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City | REPUBLIC
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State | MI
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Zip | 49879-9131
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Country | US
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Telephone | 906-282-3130
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Fax |
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Provider Business Mailing Address
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Address Line | 191 HEMLOCK STREET
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City | REPUBLIC
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State | MI
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Zip | 49879
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Country | US
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Telephone | 906-376-2643
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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 | 6401015102
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License Number State | MI
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