Provider Demographics
NPI:1568023901
Name:CANYON, TATIANA (LLMSW)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:CANYON
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 1:33147 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1822
Mailing Address - Country:US
Mailing Address - Phone:586-277-3752
Mailing Address - Fax:
Practice Address - Street 1:5880 N CANTON CENTER RD STE 410
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2686
Practice Address - Country:US
Practice Address - Phone:313-652-2432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011043151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical