Provider Demographics
NPI:1992752075
Name:ESHELMAN, TINA LOUISE (CSW)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:ESHELMAN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 IROQUOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1109
Mailing Address - Country:US
Mailing Address - Phone:248-399-9524
Mailing Address - Fax:
Practice Address - Street 1:13087 E 11 MILE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-4782
Practice Address - Country:US
Practice Address - Phone:586-754-3060
Practice Address - Fax:586-754-4010
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801062199104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
N47440010Medicare PIN