Provider Demographics
NPI:1073688784
Name:EDINGER, TAMARA SUE (LMSW, ACSW)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:SUE
Last Name:EDINGER
Suffix:
Gender:F
Credentials:LMSW, ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49204-0271
Mailing Address - Country:US
Mailing Address - Phone:517-782-8055
Mailing Address - Fax:
Practice Address - Street 1:2301 E MICHIGAN AVE STE 108
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3765
Practice Address - Country:US
Practice Address - Phone:517-782-8055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010819451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI19416Medicaid
MICARE CHOICESOther138623
MI240366OtherCOMPSYCH
MI8008921080OtherBCBSMI
MIAETNAOther7554568
MICARE CHOICESOther138623