Provider Demographics
NPI:1891380846
Name:RADINA, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:RADINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2060 CHAMPAGNE DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-2559
Mailing Address - Country:US
Mailing Address - Phone:989-798-8413
Mailing Address - Fax:
Practice Address - Street 1:3115 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5131
Practice Address - Country:US
Practice Address - Phone:734-975-1602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801100529104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker