Provider Demographics
NPI:1245801521
Name:TERRELL, TAMMY LATICE (LMSW)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:LATICE
Last Name:TERRELL
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-4825
Mailing Address - Country:US
Mailing Address - Phone:734-999-2150
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:734-999-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6851110472101YM0800X
MI68011104721041C0700X
MI6851110472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical