Provider Demographics
NPI:1912142035
Name:PORT HURON COUNSELING BEHAVIORAL SPECIALIST
Entity type:Organization
Organization Name:PORT HURON COUNSELING BEHAVIORAL SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CO
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAGLIONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-414-0754
Mailing Address - Street 1:42928 VERSAILLES RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2344
Mailing Address - Country:US
Mailing Address - Phone:810-488-7974
Mailing Address - Fax:
Practice Address - Street 1:309 MCMORRAN BLVD
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3807
Practice Address - Country:US
Practice Address - Phone:810-488-7974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010554492084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2607611202OtherBLUE CROSS