Provider Demographics
NPI:1760933121
Name:FLEIS, TARA (LLPC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:FLEIS
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 1:191 HEMLOCK STREET
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MI
Mailing Address - Zip Code:49879
Mailing Address - Country:US
Mailing Address - Phone:906-376-2643
Mailing Address - Fax:
Practice Address - Street 1:9885 STATE HIGHWAY M95
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MI
Practice Address - Zip Code:49879-9131
Practice Address - Country:US
Practice Address - Phone:906-282-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health