Provider Demographics
NPI:1003321357
Name:MATLOCK, TAMIKA L (BSW, LPC)
Entity Type:Individual
Prefix:
First Name:TAMIKA
Middle Name:L
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:BSW, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 LOTHROP RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2736
Mailing Address - Country:US
Mailing Address - Phone:313-802-6546
Mailing Address - Fax:
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1024
Practice Address - Country:US
Practice Address - Phone:313-664-6814
Practice Address - Fax:313-833-5973
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802076257104100000X
MI6401010407101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker