Provider Demographics
NPI:1205180106
Name:CARR, TYEISHA LATINA
Entity Type:Individual
Prefix:MS
First Name:TYEISHA
Middle Name:LATINA
Last Name:CARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17421 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3165
Mailing Address - Country:US
Mailing Address - Phone:313-531-2500
Mailing Address - Fax:313-255-3465
Practice Address - Street 1:17421 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3165
Practice Address - Country:US
Practice Address - Phone:313-531-2500
Practice Address - Fax:313-255-3465
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI6801096791104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)