MEDICARE: MS. TINA LOUISE LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801092871	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0964543	OTHER		BCBSMI

General Provider Information

NPI Number	:	1336433101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TINA LOUISE LMSW

Provider Business Mailing Address
First Line	:	26711 WOODWARD AVE STE 208
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1368
Country	:	US
Telephone Number	:	248-703-4920
Fax Number	:	248-458-4183

Provider Business Practice Location Address
First Line	:	26711 WOODWARD AVE STE 208
Second Line	:
City	:	HUNTINGTON WOODS
State	:	MI
Zip	:	48070-1368
Country	:	US
Telephone Number	:	248-703-4920
Fax Number	:	248-458-4183

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	06/11/2019

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