Healthcare Provider Details

I. General information

NPI: 1245352087
Provider Name (Legal Business Name): MAXINE A THOME SOCIAL WORKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 OSBORN ROAD
LANSING MI
48915
US

IV. Provider business mailing address

1531 OSBORN ROAD
LANSING MI
48915
US

V. Phone/Fax

Practice location:
  • Phone: 517-881-5074
  • Fax:
Mailing address:
  • Phone: 517-881-5074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801012634
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: