Provider Demographics
NPI:1144837543
Name:CARNEY, TAVARES
Entity type:Individual
Prefix:
First Name:TAVARES
Middle Name:
Last Name:CARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25614 W 12 MILE RD APT 305
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8034
Mailing Address - Country:US
Mailing Address - Phone:248-631-7489
Mailing Address - Fax:
Practice Address - Street 1:2900 BRUSH ST APT 323
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2655
Practice Address - Country:US
Practice Address - Phone:248-631-7489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor