MEDICARE: MS. DOROTHY EILEEN TETREAULT 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	6801081579	MI

General Provider Information

NPI Number	:	1912041344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DOROTHY EILEEN TETREAULT LMSW

Provider Business Mailing Address
First Line	:	2301 E MICHIGAN AVE
Second Line	:	SUITE 209
City	:	JACKSON
State	:	MI
Zip	:	49202-3700
Country	:	US
Telephone Number	:	571-787-8170
Fax Number	:

Provider Business Practice Location Address
First Line	:	569 WILDWOOD AVE
Second Line	:	UNIT 4
City	:	JACKSON
State	:	MI
Zip	:	49201-1048
Country	:	US
Telephone Number	:	517-788-6404
Fax Number	:	517-787-8170

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

Provider Enumeration Date	:	02/18/2007
Last Update Date	:	08/09/2019

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