Basic Information
| Provider Information | |||||||||
| NPI: | 1760840623 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUFORT | ||||||||
| FirstName: | TAMRA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 778 EAST DOPP RD | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898594768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 218 FAST ICE DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896312320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2016 | ||||||||
| LastUpdateDate: | 02/08/2016 | ||||||||
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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 | 104100000X | 6802088023 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.