Healthcare Provider Details

I. General information

NPI: 1114845435
Provider Name (Legal Business Name): ALEX JORDAN THOMAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 LIVERNOIS ST UNIT 1
FERNDALE MI
48220-2304
US

IV. Provider business mailing address

21694 WOODCREST CT
FARMINGTON HILLS MI
48335-4243
US

V. Phone/Fax

Practice location:
  • Phone: 248-307-7496
  • Fax:
Mailing address:
  • Phone: 248-991-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010346
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: