Provider Demographics
NPI:1932249182
Name:LEMMEN, TYRA VAN GILDER (MSW)
Entity type:Individual
Prefix:MS
First Name:TYRA
Middle Name:VAN GILDER
Last Name:LEMMEN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:TYRA
Other - Middle Name:
Other - Last Name:VAN GILDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:3122 FAIRHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9665
Mailing Address - Country:US
Mailing Address - Phone:734-665-7245
Mailing Address - Fax:
Practice Address - Street 1:425 E WASHINGTON ST
Practice Address - Street 2:SUITE 101-A
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-2024
Practice Address - Country:US
Practice Address - Phone:734-995-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010350761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI80-0-89-2292-0OtherBC BS PIN OR CPC
MI0-89-22924-801Medicare ID - Type UnspecifiedMEDICARE CPC