Healthcare Provider Details

I. General information

NPI: 1104913177
Provider Name (Legal Business Name): THOMAS EDWARD HAEFNER LLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33101 ANNAPOLIS ST
WAYNE MI
48184-2405
US

IV. Provider business mailing address

29814 OAKLEY ST
LIVONIA MI
48154-3736
US

V. Phone/Fax

Practice location:
  • Phone: 734-721-0200
  • Fax: 734-721-1766
Mailing address:
  • Phone: 734-762-6248
  • Fax: 734-762-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301009928
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: