Provider Demographics
NPI:1710643531
Name:SHIVERS, TAMARA GHESQUIERE (LLPC)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:GHESQUIERE
Last Name:SHIVERS
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 SAINT ANDREWS
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4295
Mailing Address - Country:US
Mailing Address - Phone:810-650-2732
Mailing Address - Fax:
Practice Address - Street 1:2601 13TH ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6546
Practice Address - Country:US
Practice Address - Phone:810-987-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451020907101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health