Basic Information
| Provider Information | |||||||||
| NPI: | 1750616124 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | TAMILYN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC, NCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FREY | ||||||||
| OtherFirstName: | TAMILYN | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | LPC, NCC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15954 RIVERS EDGE | ||||||||
| Address2: | 15954 RIVERS EDGE DRIVE | ||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7159345090 | ||||||||
| Practice Location | |||||||||
| Address1: | NORTHLAKES COMMUNITY CLINIC | ||||||||
| Address2: | 15954 RIVERS EDGE DRIVE | ||||||||
| City: | HAYWARD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548435484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7156342541 | ||||||||
| FaxNumber: | 7159345090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2009 | ||||||||
| LastUpdateDate: | 02/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 4272-125 | WI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.