Provider Demographics
NPI:1861206716
Name:CARTER, TIA FIANNA (LLC)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:FIANNA
Last Name:CARTER
Suffix:
Gender:
Credentials:LLC
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:F
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1010 E WEST MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-3571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 E WEST MAPLE RD
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3571
Practice Address - Country:US
Practice Address - Phone:248-313-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023946101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional