MEDICARE: DOT TETREAULT, LMSW, ACSW PLLC

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	101YM0800X	Mental Health Counselor	6801081579	MI

General Provider Information

NPI Number	:	1528342516
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOT TETREAULT, LMSW, ACSW PLLC

Provider Business Mailing Address
First Line	:	569 WILDWOOD AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-1048
Country	:	US
Telephone Number	:	517-787-8170
Fax Number	:	517-787-8170

Provider Business Practice Location Address
First Line	:	569 WILDWOOD AVE
Second Line	:
City	:	JACKSON
State	:	MI
Zip	:	49201-1048
Country	:	US
Telephone Number	:	517-787-8170
Fax Number	:	517-787-8170

Authorized Official
Title or Position	:	OWNER
Name	:	DORORTHY E TETREAULT
Credential	:	LMSW, ACSW
Telephone Number	:	517-787-8170

Provider Enumeration Date	:	10/08/2011
Last Update Date	:	07/23/2014

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