Provider Demographics
NPI:1215426564
Name:HENNIGAR, TAMA (BS, QIDP, QMHP)
Entity type:Individual
Prefix:
First Name:TAMA
Middle Name:
Last Name:HENNIGAR
Suffix:
Gender:F
Credentials:BS, QIDP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5805 CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-9499
Mailing Address - Country:US
Mailing Address - Phone:989-739-1469
Mailing Address - Fax:
Practice Address - Street 1:5805 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-9499
Practice Address - Country:US
Practice Address - Phone:989-739-1469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-02
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician