Provider Demographics
NPI:1720321458
Name:ANTISHIN, TAMARA JUNE (LMSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:JUNE
Last Name:ANTISHIN
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 1:888 W BIG BEAVER RD STE 780
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4745
Mailing Address - Country:US
Mailing Address - Phone:248-270-5660
Mailing Address - Fax:
Practice Address - Street 1:888 W BIG BEAVER RD STE 780
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4745
Practice Address - Country:US
Practice Address - Phone:248-270-5660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-01
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010945441041C0700X, 104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical