MEDICARE: MS. THALIA MARIE FERENC L.M.S.W.

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	1041C0700X	Clinical Social Worker	6801059745	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11573200	OTHER	MI	CAQH

General Provider Information

NPI Number	:	1831309392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THALIA MARIE FERENC L.M.S.W.

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

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	02/02/2019

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