Basic Information
| Provider Information | |||||||||
| NPI: | 1801820444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TINDALE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JO-ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TINDALE | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 44480 HEYDENREICH RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137298160 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Practice Location | |||||||||
| Address1: | 22811 GREATER MACK AVE STE L2 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863352006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 08/16/2018 | ||||||||
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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 | 1041C0700X | 6801067441 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |