=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780010728
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA RENAE STANLEY LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2013
-----------------------------------------------------
Last Update Date | 08/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 527 COBB ST
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-2540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-876-3293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4291 RIDGEWAY TRL
-----------------------------------------------------
City | LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48632-9156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-912-0122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------