MEDICARE: INTERSECTIONAL INSIGHT, 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	103T00000X	Psychologist
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1558832873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERSECTIONAL INSIGHT, PLLC

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	:	OWNER/MANAGER
Name	:	TINA LOUISE
Credential	:	LMSW
Telephone Number	:	248-703-4920

Provider Enumeration Date	:	12/14/2018
Last Update Date	:	12/14/2018

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