Provider Demographics
NPI:1063130318
Name:TEBAR, MARILYN ROSE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:ROSE
Last Name:TEBAR
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 1:903 E LIBERTY LN LOT 35
Mailing Address - Street 2:
Mailing Address - City:WHITE CLOUD
Mailing Address - State:MI
Mailing Address - Zip Code:49349-8786
Mailing Address - Country:US
Mailing Address - Phone:231-923-2694
Mailing Address - Fax:
Practice Address - Street 1:15320 WALDRON WAY
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-8723
Practice Address - Country:US
Practice Address - Phone:231-527-7333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool