Provider Demographics
NPI:1134904972
Name:JURGENSEN, TANDY (LPC, LLMFT)
Entity type:Individual
Prefix:
First Name:TANDY
Middle Name:
Last Name:JURGENSEN
Suffix:
Gender:F
Credentials:LPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10535 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1565
Mailing Address - Country:US
Mailing Address - Phone:248-979-1219
Mailing Address - Fax:
Practice Address - Street 1:27172 WOODWARD AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0965
Practice Address - Country:US
Practice Address - Phone:248-979-1219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401015001101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor