Provider Demographics
NPI:1104906122
Name:LOFTIS, MICHAEL WAYNE (LCSW)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:LOFTIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 ROB LN
Mailing Address - Street 2:
Mailing Address - City:LASCASSAS
Mailing Address - State:TN
Mailing Address - Zip Code:37085-4635
Mailing Address - Country:US
Mailing Address - Phone:615-890-7946
Mailing Address - Fax:615-890-7946
Practice Address - Street 1:2670 MEMORIAL BLVD
Practice Address - Street 2:SUITE E-2
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-5139
Practice Address - Country:US
Practice Address - Phone:615-890-7946
Practice Address - Fax:615-890-7946
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN36631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3075520OtherBLUE CROSS BLUE SHIELD #
TN3699674Medicare ID - Type UnspecifiedSOCIAL WORKER