Provider Demographics
NPI:1336648179
Name:HALLIBURTON, TAMARA LYNN
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:HALLIBURTON
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 1:23077 GREENFIELD RD
Mailing Address - Street 2:SUITE 455 PMB 1063
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3740
Mailing Address - Country:US
Mailing Address - Phone:313-683-2753
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 455
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3740
Practice Address - Country:US
Practice Address - Phone:313-683-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016351101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health