Basic Information
| Provider Information | |||||||||
| NPI: | 1366627291 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGSTAFF | ||||||||
| FirstName: | TAMMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPC, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 735 BARRINGTON RD | ||||||||
| Address2: | |||||||||
| City: | GROSSE POINTE PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482301724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138223938 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42669 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864125321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2008 | ||||||||
| LastUpdateDate: | 04/28/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401007402 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.