Provider Demographics
NPI:1902207624
Name:BLAND, TYSHAUN (BS; MA)
Entity Type:Individual
Prefix:
First Name:TYSHAUN
Middle Name:
Last Name:BLAND
Suffix:
Gender:M
Credentials:BS; MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19927 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1621
Mailing Address - Country:US
Mailing Address - Phone:313-627-8719
Mailing Address - Fax:313-216-1776
Practice Address - Street 1:19927 COUNTRY CLUB
Practice Address - Street 2:
Practice Address - City:HARPER WOODS
Practice Address - State:MI
Practice Address - Zip Code:48225-1154
Practice Address - Country:US
Practice Address - Phone:313-627-8719
Practice Address - Fax:313-216-1776
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-01445101YA0400X
103K00000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst