Healthcare Provider Details

I. General information

NPI: 1013300557
Provider Name (Legal Business Name): LENIN THOMAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 03/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER NE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

21540 PROVINCIAL BLVD APT- 2518
KATY TX
77450
US

V. Phone/Fax

Practice location:
  • Phone: 616-304-7768
  • Fax:
Mailing address:
  • Phone: 616-304-7768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801086866
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: