Provider Demographics
NPI:1356417034
Name:MAITLAND, TONIA LYNN
Entity type:Individual
Prefix:
First Name:TONIA
Middle Name:LYNN
Last Name:MAITLAND
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 1:12237 MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:MI
Mailing Address - Zip Code:48457-8802
Mailing Address - Country:US
Mailing Address - Phone:810-639-6386
Mailing Address - Fax:
Practice Address - Street 1:12237 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:MI
Practice Address - Zip Code:48457-8802
Practice Address - Country:US
Practice Address - Phone:810-639-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF250065418320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities