Provider Demographics
NPI:1124459979
Name:HERDELL, TANI M (MS)
Entity type:Individual
Prefix:
First Name:TANI
Middle Name:M
Last Name:HERDELL
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28555 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2973
Mailing Address - Country:US
Mailing Address - Phone:248-788-4300
Mailing Address - Fax:248-605-8099
Practice Address - Street 1:28555 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 106
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2973
Practice Address - Country:US
Practice Address - Phone:248-788-4300
Practice Address - Fax:248-605-8099
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013959103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist