MEDICARE: THALIA FERENC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	900032412	OTHER	MI	PRIORITY HEALTH
3	MI2873	OTHER	MI	BCBSM

General Provider Information

NPI Number	:	1538633821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THALIA FERENC LLC

Provider Business Mailing Address
First Line	:	6127 BAY SHORE WEST DR
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-9173
Country	:	US
Telephone Number	:	231-838-3222
Fax Number	:

Provider Business Practice Location Address
First Line	:	6127 BAY SHORE WEST DR
Second Line	:
City	:	CHARLEVOIX
State	:	MI
Zip	:	49720-9173
Country	:	US
Telephone Number	:	231-838-2322
Fax Number	:	231-622-8126

Authorized Official
Title or Position	:	PSYCHOTHERAPIST
Name	:	MS. THALIA M FERENC
Credential	:	LMSW
Telephone Number	:	231-838-2322

Provider Enumeration Date	:	01/20/2019
Last Update Date	:	01/20/2019

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Directions to “THALIA FERENC LLC ” Practice Location

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