Basic Information
| Provider Information | |||||||||
| NPI: | 1184171498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMCM4 LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10 | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488540010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176769788 | ||||||||
| FaxNumber: | 8667767556 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 WOODLAND PASS STE 216 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488232060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173476944 | ||||||||
| FaxNumber: | 5173476912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2016 | ||||||||
| LastUpdateDate: | 05/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | HOUPT | ||||||||
| AuthorizedOfficialFirstName: | MARY BETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 5176769788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801059540 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.