Provider Demographics
NPI:1952859266
Name:KREIFELDT, TAMARA
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:KREIFELDT
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 1:521 E ELLEN ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-2122
Mailing Address - Country:US
Mailing Address - Phone:810-931-9092
Mailing Address - Fax:
Practice Address - Street 1:521 E ELLEN ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2122
Practice Address - Country:US
Practice Address - Phone:810-931-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-15
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000XOtherTECHNICIAN