Healthcare Provider Details

I. General information

NPI: 1912575861
Provider Name (Legal Business Name): NDIAGA THIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAMPUS DR
HANCOCK MI
49930-1452
US

IV. Provider business mailing address

301 EXPLORER ST
GWINN MI
49841-2813
US

V. Phone/Fax

Practice location:
  • Phone: 906-483-1060
  • Fax: 906-372-3230
Mailing address:
  • Phone: 906-481-8586
  • Fax: 906-483-1394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451024080
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: