Provider Demographics
NPI:1154182517
Name:MCCRAY, TANISHA LALASHANN
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:LALASHANN
Last Name:MCCRAY
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 1:21228 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-4357
Mailing Address - Country:US
Mailing Address - Phone:313-647-2482
Mailing Address - Fax:
Practice Address - Street 1:175 N GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1562
Practice Address - Country:US
Practice Address - Phone:586-255-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker