Basic Information
| Provider Information | |||||||||
| NPI: | 1154712735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCBAIN | ||||||||
| FirstName: | TRISTAN | ||||||||
| MiddleName: | DANIELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEHAVEN | ||||||||
| OtherFirstName: | TRISTAN | ||||||||
| OtherMiddleName: | DANIELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 330 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177877920 | ||||||||
| FaxNumber: | 5177967987 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 W MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492012121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177877920 | ||||||||
| FaxNumber: | 5177967987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2015 | ||||||||
| LastUpdateDate: | 02/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 6401014695 | MI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.