Provider Demographics
NPI:1336433101
Name:LOUISE, TINA (LMSW)
Entity Type:Individual
Prefix:MS
First Name:TINA
Middle Name:
Last Name:LOUISE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26711 WOODWARD AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48070-1368
Mailing Address - Country:US
Mailing Address - Phone:248-703-4920
Mailing Address - Fax:248-458-4183
Practice Address - Street 1:26711 WOODWARD AVE STE 208
Practice Address - Street 2:
Practice Address - City:HUNTINGTON WOODS
Practice Address - State:MI
Practice Address - Zip Code:48070-1368
Practice Address - Country:US
Practice Address - Phone:248-703-4920
Practice Address - Fax:248-458-4183
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010928711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
0964543OtherBCBSMI