Healthcare Provider Details

I. General information

NPI: 1922742980
Provider Name (Legal Business Name): ADAM GERARD THIBODEAU LLMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 S MAIN ST STE C
MILFORD MI
48381-1975
US

IV. Provider business mailing address

5297 LANCASTER HILLS DR
CLARKSTON MI
48346-4424
US

V. Phone/Fax

Practice location:
  • Phone: 248-529-6383
  • Fax:
Mailing address:
  • Phone: 313-452-5751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6851114072
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851114072
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: