Provider Demographics
NPI:1689748121
Name:FORTON, TARA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:FORTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25594 CORTEZ ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2028
Mailing Address - Country:US
Mailing Address - Phone:586-321-3029
Mailing Address - Fax:586-465-2341
Practice Address - Street 1:25594 CORTEZ ST
Practice Address - Street 2:
Practice Address - City:HARRISON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48045-2028
Practice Address - Country:US
Practice Address - Phone:586-321-3029
Practice Address - Fax:586-465-2341
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801082238101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP30230Medicare ID - Type Unspecified