Provider Demographics
NPI:1023371895
Name:HENRY, TIA LOUISE (LCSW, LMSW)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:LOUISE
Last Name:HENRY
Suffix:
Gender:F
Credentials:LCSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2009 HUNTINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1981
Mailing Address - Country:US
Mailing Address - Phone:313-330-2901
Mailing Address - Fax:
Practice Address - Street 1:2009 HUNTINGTON BLVD
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1981
Practice Address - Country:US
Practice Address - Phone:313-330-2901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010636121041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical