Provider Demographics
NPI:1740726488
Name:SMITH, TANISHA (MA, TLLP)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14620 FAUST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2305
Mailing Address - Country:US
Mailing Address - Phone:313-231-5323
Mailing Address - Fax:
Practice Address - Street 1:14620 FAUST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223
Practice Address - Country:US
Practice Address - Phone:313-231-5323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician