Provider Demographics
NPI:1467903963
Name:SHIFLETT, TAMARA ROSE KUJAWA (LMSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:ROSE KUJAWA
Last Name:SHIFLETT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:TAMMY
Other - Middle Name:KUJAWA
Other - Last Name:SHIFLETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMSW
Mailing Address - Street 1:214 S BRIDGE ST STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-1587
Mailing Address - Country:US
Mailing Address - Phone:517-231-7394
Mailing Address - Fax:
Practice Address - Street 1:214 S BRIDGE ST STE C
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-1587
Practice Address - Country:US
Practice Address - Phone:517-231-7394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010928061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1972096543Medicaid