Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | 6401010407 | MI |
N | 104100000X | Social Worker | 6802076257 | MI |
NPI | 1003321357 |
---|---|
Provider Name | Tamika L. Matlock |
First Address | Detroit, MI 48202-2736 |
Second Address | Detroit, MI 48207-1024 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2017 |
Last Update Date | 08/12/2017 |