Provider Demographics
NPI:1881137727
Name:REDDICK, TANIESHA IVY (LPC)
Entity type:Individual
Prefix:
First Name:TANIESHA
Middle Name:IVY
Last Name:REDDICK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16729 FERGUSON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3444
Mailing Address - Country:US
Mailing Address - Phone:313-363-1247
Mailing Address - Fax:
Practice Address - Street 1:30150 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4519
Practice Address - Country:US
Practice Address - Phone:313-363-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-26
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401222577101Y00000X
MI6401015757101YA0400X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health