Provider Demographics
NPI:1679235030
Name:MONFORTON, DANA KATHARINE (TLLP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:KATHARINE
Last Name:MONFORTON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 E MAPLEHURST ST
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1382
Mailing Address - Country:US
Mailing Address - Phone:248-408-7314
Mailing Address - Fax:
Practice Address - Street 1:2490 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1484
Practice Address - Country:US
Practice Address - Phone:248-281-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009387103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical