Provider Demographics
NPI:1861437626
Name:TABASHNECK, BRUCE ALAN (LMSW, ACSW, MI)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALAN
Last Name:TABASHNECK
Suffix:
Gender:M
Credentials:LMSW, ACSW, MI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2856 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-2153
Mailing Address - Country:US
Mailing Address - Phone:248-207-2165
Mailing Address - Fax:
Practice Address - Street 1:29865 6 MILE RD
Practice Address - Street 2:SUITE 112
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3673
Practice Address - Country:US
Practice Address - Phone:734-522-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010150551041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool