Provider Demographics
NPI:1013569920
Name:PRYOR, TATYANA AUBREY (LLMSW)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:AUBREY
Last Name:PRYOR
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4848 WASHTENAW AVE APT C4
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1487
Mailing Address - Country:US
Mailing Address - Phone:661-549-0515
Mailing Address - Fax:
Practice Address - Street 1:6821 MEDBURY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-3317
Practice Address - Country:US
Practice Address - Phone:313-922-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801105087104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker