Healthcare Provider Details

I. General information

NPI: 1154737872
Provider Name (Legal Business Name): CRYSTAL THOMAS, LLMSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 S ELMWOOD AVE SUITE C
TRAVERSE CITY MI
49684-2191
US

IV. Provider business mailing address

821 S ELMWOOD AVE SUITE C
TRAVERSE CITY MI
49684-2191
US

V. Phone/Fax

Practice location:
  • Phone: 231-735-0144
  • Fax: 231-947-2444
Mailing address:
  • Phone: 231-735-0144
  • Fax: 231-947-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093486
License Number StateMI

VIII. Authorized Official

Name: CRYSTAL THOMAS
Title or Position: OWNER
Credential: LMSW
Phone: 231-735-0144