Provider Demographics
NPI:1538731666
Name:TAVERNER, MICHELLE DEANNA (LMSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DEANNA
Last Name:TAVERNER
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 1:24367 ROMA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-2963
Mailing Address - Country:US
Mailing Address - Phone:734-536-1680
Mailing Address - Fax:
Practice Address - Street 1:24367 ROMA RIDGE DR
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374
Practice Address - Country:US
Practice Address - Phone:734-536-1680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010849421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical