Healthcare Provider Details

I. General information

NPI: 1972625424
Provider Name (Legal Business Name): PROFESSIONAL PSYCHOLOGICAL & REHABILITATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 10/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 W ST JOSEPH HWY, SUITE A101
LANSING MI
48917
US

IV. Provider business mailing address

3815 W ST JOSEPH HWY, SUITE A101
LANSING MI
48917
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-5900
  • Fax: 517-321-5945
Mailing address:
  • Phone: 517-321-5900
  • Fax: 517-321-5945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801063438
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301003971
License Number StateMI

VIII. Authorized Official

Name: DR. HILTON T THOMAS
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 517-321-5900