Provider Demographics
NPI:1366731879
Name:TRI-CARE PC. DBA NORTHLAND CLINIC
Entity type:Organization
Organization Name:TRI-CARE PC. DBA NORTHLAND CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-559-8190
Mailing Address - Street 1:20300 CIVIC CENTER DR
Mailing Address - Street 2:STE. 303
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4105
Mailing Address - Country:US
Mailing Address - Phone:248-559-8190
Mailing Address - Fax:248-559-8776
Practice Address - Street 1:20300 CIVIC CENTER DR
Practice Address - Street 2:STE. 303
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4105
Practice Address - Country:US
Practice Address - Phone:248-559-8190
Practice Address - Fax:248-559-8776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010005311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty