Provider Demographics
NPI:1508275694
Name:EDISON, TANZELLA (LPC)
Entity Type:Individual
Prefix:MS
First Name:TANZELLA
Middle Name:
Last Name:EDISON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2192 PRINCE HALL DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5110
Mailing Address - Country:US
Mailing Address - Phone:313-407-1578
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-407-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012965101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional