Provider Demographics
NPI:1497327431
Name:HEATON-WYRICK, TAMARA (LLMSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:HEATON-WYRICK
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 1:18 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4645
Mailing Address - Country:US
Mailing Address - Phone:248-320-6343
Mailing Address - Fax:
Practice Address - Street 1:1750 S TELEGRAPH RD STE 101
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0177
Practice Address - Country:US
Practice Address - Phone:248-451-9085
Practice Address - Fax:248-451-9089
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011099011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical