Basic Information
| Provider Information | |||||||||
| NPI: | 1336414861 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURTELL | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPC, NCC, CAADC | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2012 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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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 | 101YP2500X | 6401012886 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 213119549 | 05 | MI | MEDICAID |