Provider Demographics
NPI:1588698260
Name:PETOSKEY, TYRA M (LMSW, CAADC)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:M
Last Name:PETOSKEY
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4472 KILLARNEY PARK DR
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1823
Mailing Address - Country:US
Mailing Address - Phone:810-962-3556
Mailing Address - Fax:
Practice Address - Street 1:2442 E MAPLE AVE STE 204C
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-4491
Practice Address - Country:US
Practice Address - Phone:810-962-3556
Practice Address - Fax:810-963-8359
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010788681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG96288048Medicare PIN