Healthcare Provider Details

I. General information

NPI: 1609128503
Provider Name (Legal Business Name): JOANN THOMPSON MA, TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2925 RUSSELL ST
DETROIT MI
48207-4825
US

IV. Provider business mailing address

355 AUBURN AVE
PONTIAC MI
48342-3206
US

V. Phone/Fax

Practice location:
  • Phone: 313-396-5353
  • Fax:
Mailing address:
  • Phone: 248-310-4666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number103TC1900X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: