Provider Demographics
NPI:1932766557
Name:BLATT, MINA TYLERAMANDA (LMSW)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:TYLERAMANDA
Last Name:BLATT
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MINA
Other - Middle Name:
Other - Last Name:BETHEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50258 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-1374
Mailing Address - Country:US
Mailing Address - Phone:586-884-4714
Mailing Address - Fax:586-884-4693
Practice Address - Street 1:11480 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2566
Practice Address - Country:US
Practice Address - Phone:586-216-9253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011044341041C0700X
68011136771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical