Provider Demographics
NPI:1649831280
Name:EALEY, TINA (LLC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:EALEY
Suffix:
Gender:
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20216 ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2505
Mailing Address - Country:US
Mailing Address - Phone:734-366-9424
Mailing Address - Fax:
Practice Address - Street 1:20216 ALBANY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2505
Practice Address - Country:US
Practice Address - Phone:734-366-9424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401224849101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional